US5770606A - Dosage forms and method for ameliorating male erectile dysfunction - Google Patents

Dosage forms and method for ameliorating male erectile dysfunction Download PDF

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US5770606A
US5770606A US08/546,498 US54649895A US5770606A US 5770606 A US5770606 A US 5770606A US 54649895 A US54649895 A US 54649895A US 5770606 A US5770606 A US 5770606A
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apomorphine
patient
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penile
placebo
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Ragab El-Rashidy
Jeremy P. W. Heaton
Alvaro Morales
Michael A. Adams
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Queens University at Kingston
Pentech Pharmaceuticals Inc
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Pentech Pharmaceuticals Inc
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Assigned to PENTECH PHARMACEUTICALS, INC. reassignment PENTECH PHARMACEUTICALS, INC. ASSIGNMENT OF ASSIGNORS INTEREST (SEE DOCUMENT FOR DETAILS). Assignors: ADAMS, MICHAEL A., HEATON, JEREMY P.W., MORALES, ALVARO, EL-RASHIDY, RAGAB
Assigned to QUEEN'S UNIVERSITY AT KINGSTON, PENTECH PHARMACEUTICALS, INC. reassignment QUEEN'S UNIVERSITY AT KINGSTON A CORRECTIVE ASSIGNMENT TO ADD AN ADDITIONAL ASSIGNEE TO AN ASSIGNMENT PREVIOUSLY RECORDED AT REEL 7861, FRAME 915. Assignors: ADAMS, MICHAEL A., HEATON, JEREMY P.W., MORALES, ALVARO, EL-RASHIDY, RAGAB
Priority to US09/102,406 priority patent/US6121276A/en
Priority to US09/102,235 priority patent/US5985889A/en
Publication of US5770606A publication Critical patent/US5770606A/en
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Priority to US09/336,088 priority patent/US6395744B1/en
Priority to US09/440,451 priority patent/US6200983B1/en
Priority to US09/606,919 priority patent/US6306437B1/en
Priority to US10/044,588 priority patent/US6566368B2/en
Priority to US10/126,933 priority patent/US6756407B2/en
Priority to US10/136,387 priority patent/US20020165122A1/en
Priority to US10/440,760 priority patent/US20040092493A1/en
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/47—Quinolines; Isoquinolines
    • A61K31/473—Quinolines; Isoquinolines ortho- or peri-condensed with carbocyclic ring systems, e.g. acridines, phenanthridines
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/47—Quinolines; Isoquinolines
    • A61K31/485—Morphinan derivatives, e.g. morphine, codeine
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K49/00—Preparations for testing in vivo
    • A61K49/0004—Screening or testing of compounds for diagnosis of disorders, assessment of conditions, e.g. renal clearance, gastric emptying, testing for diabetes, allergy, rheuma, pancreas functions
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K9/00—Medicinal preparations characterised by special physical form
    • A61K9/0012—Galenical forms characterised by the site of application
    • A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
    • A61K9/0056—Mouth soluble or dispersible forms; Suckable, eatable, chewable coherent forms; Forms rapidly disintegrating in the mouth; Lozenges; Lollipops; Bite capsules; Baked products; Baits or other oral forms for animals
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K9/00—Medicinal preparations characterised by special physical form
    • A61K9/0012—Galenical forms characterised by the site of application
    • A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
    • A61K9/006—Oral mucosa, e.g. mucoadhesive forms, sublingual droplets; Buccal patches or films; Buccal sprays
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P15/00—Drugs for genital or sexual disorders; Contraceptives
    • A61P15/10—Drugs for genital or sexual disorders; Contraceptives for impotence

Definitions

  • This invention in one aspect, relates to dosage forms and methods for ameliorating erectile dysfunction in psychogenic male patients. In another aspect this invention relates to diagnosis of erectile dysfunction. More particularly, this invention relates to the use of apomorphine-containing compositions for amelioration of erectile dysfunction in psychogenic male patients and for diagnostic purposes.
  • a normal erection occurs as a result of a coordinated vascular event in the penis. This is usually triggered neurally and consists of vasodilation and smooth muscle relaxation in the penis and its supplying arterial vessels. Arterial inflow causes enlargement of the substance of the corpora cavernosa. Venous outflow is trapped by this enlargement, permitting sustained high blood pressures in the penis sufficient to cause rigidity. Muscles in the perineum also assist in creating and maintaining penile rigidity. Erection may be induced centrally in the nervous system by sexual thoughts or fantasy, and is usually reinforced locally by reflex mechanisms. Erectile mechanics are substantially similar in the female for the clitoris.
  • Impotence or male erectile dysfunction is defined as the inability to achieve and sustain an erection sufficient for intercourse. Impotence in any given case can result from psychological disturbances (psychogenic), from physiological abnormalities in general (organic), from neurological disturbances (neurogenic), hormonal deficiencies (endocrine) or from a combination of the foregoing.
  • psychogenic impotence is defined as functional impotence with no apparent overwhelming organic basis. It may be characterized by an ability to have an erection in response to some stimuli (e.g., masturbation, spontaneous nocturnal, spontaneous early morning, video erotica, etc.) but not others (e.g., partner or spousal attention).
  • stimuli e.g., masturbation, spontaneous nocturnal, spontaneous early morning, video erotica, etc.
  • others e.g., partner or spousal attention
  • the ointment consists of the vasodilators papaverine, hydralazine, sodium nitroprusside, phenoxybenzamine, or phentolamine and a carrier to assist absorption of the primary agent through the skin.
  • U.S. Pat. No. 5,256,652 to El-Rashidy teaches the use of an aqueous topical composition of a vasodilator such as papaverine together with hydroxypropyl- ⁇ -cyclodextrin.
  • apomorphine has been shown to have very poor oral bioavailability. See, for example, Baldessarini et al., in Gessa et al., eds., Apomorphine and Other Dopaminomimetics, Basic Pharmacology, Vol. 1, Raven Press, N.Y. (1981), pp. 219-228.
  • Sublingual apomorphine dosage forms usually containing about 2.5 to about 10 milligrams of apomorphine, have been found to be effective in male patients suffering from psychogenic erectile dysfunction for the induction and maintenance of an erection sufficient for intercourse (i.e., vaginal penetration) without nausea or other undesirable side effects.
  • the apomorphine is administered sublingually, preferably about 15 to about 20 minutes prior to sexual activity, and so as to maintain a predetermined circulating serum levels and mid-brain tissue levels of apomorphine during the period of sexual activity sufficient to induce an erection adequate for vaginal penetration but less than the amount that induces nausea.
  • the plasma concentration of apomorphine should be maintained at no more than about 5.5 nanograms per milliliter, preferably about 0.3 to about 4 nanograms per milliliter, and more preferably about 1 to about 2 nanograms per milliliter.
  • the foregoing sublingual apomorphine dosage forms are also suitable for screening patients complaining of erectile dysfunction so as to identify patients of psychogenic etiology.
  • FIG. 1 is a graphical representation of mean erectile function, expressed as RIGISCANTM monitor value, as a function of apomorphine dose;
  • FIG. 2 is a bar graph depicting the percent successful erectile function for placebo, 3-milligram apomorphine dose, and 4-milligram apomorphine dose under erotic and neutral conditions;
  • FIG. 3 is a bar graph presenting yet another comparison of erectile function noted in Pilot Study #4 in terms of RIGISCANTM monitor score versus placebo, 3 milligrams of apomorphine and 4 milligrams of apomorphine under erotic and neutral conditions;
  • Apomorphine is a dopamine receptor agonist that has a recognized use as an emetic when administered subcutaneously in about a 5-milligram dose.
  • apomorphine or a similarly acting dopamine receptor agonist is administered in an amount sufficient to excite cells in the mid-brain region of the patient but with minimal side effects. This cell excitation is believed to be part of a cascade of stimulation that is likely to include neurotransmission with serotonin and oxytocin.
  • the dopamine receptors in the mid-brain region of a patient can be stimulated to a degree sufficient to cause an erection by the sublingual administration of apomorphine so as to maintain a plasma concentration of apomorphine of no more than about 5.5 nanograms per milliliter (5.5 ng/ml).
  • the sublingual administration usually takes place over a time period in the range of about 2 to about 10 minutes, or longer.
  • the amount of apomorphine administered sublingually over this time period preferably is in the range of about 25 micrograms per kilogram ( ⁇ g/kg) of body weight to about 60 ⁇ g/kg of body weight.
  • the apomorphine is administered preferably about 15 to about 20 minutes prior to sexual activity.
  • Apomorphine can be represented by the formula ##STR1## and exists in a free base form or as an acid addition salt.
  • apomorphine hydrochloride is preferred; however, other pharmacologically acceptable moieties thereof can be utilized as well.
  • the term "apomorphine" as used herein includes the free base form of this compound as well as the pharmacologically acceptable acid addition salts thereof.
  • other acceptable acid addition salts are the hydrobromide, the hydroiodide, the bisulfate, the phosphate, the acid phosphate, the lactate, the citrate, the tartarate, the salicylate, the succinate, the maleate, the gluconate, and the like.
  • Illustrative preferred sublingual dosage forms are set forth in Table I, below.
  • the presently contemplated dosage forms can also contain, in addition to tabletting excipients, ⁇ -cyclodextrin or a ⁇ -cyclodextrin derivative such as hydroxypropyl- ⁇ -cyclodextrin (HPBCD).
  • HPBCD hydroxypropyl- ⁇ -cyclodextrin
  • the onset of nausea can be obviated or delayed by delivering apomorphine at a controlled dissolution rate so as to provide circulating serum levels and mid-brain tissue levels of apomorphine sufficient for an erection without inducing nausea.
  • apomorphine is administered at or near the relatively higher amounts of the aforementioned dosage range, the likelihood of nausea onset can be reduced by concurrent administration of a ganglionic agent (inhibitor of ganglionic response) such as nicotine or lobeline sulfate.
  • a ganglionic agent inhibitor of ganglionic response
  • the weight ratio of apomorphine to ganglionic agent is in the range of about 10 to about 1.
  • antiemetic agents that can be used in conjunction with apomorphine are antidopaminergic agents such as metoclopramide, and the phenothiazines, e.g., chlorpromazine, prochlorperazine, pipamazine, thiethylperazine, oxypendyl hydrochloride, and the like.
  • antidopaminergic agents such as metoclopramide
  • phenothiazines e.g., chlorpromazine, prochlorperazine, pipamazine, thiethylperazine, oxypendyl hydrochloride, and the like.
  • serotonin (5-hydroxytryptamine or 5-HT) antagonists such as domperidone, odansetron (commercially available as the hydrochloride salt under the designation Zofran®), and the like
  • the histamine antagonists such as buclizine hydrochloride, cyclizine hydrochloride, dimenhydrinate (Dramamine), and the like
  • the parasympathetic depressants such as scopolamine, and the like
  • other anti-emetics such as metopimazine, trimethobenzamide, benzquinamine hydrochloride, diphenidol hydrochloride, and the like.
  • Nicotine-containing dosage forms and domperidone-containing dosage forms are illustrated in Table IV, below.
  • the preferred sublingual dosage forms dissolve within a time period of at least about 2 minutes but less than about 10 minutes.
  • the dissolution time can be longer, however, if desired as long as the necessary plasma concentration of apomorphine can be maintained. More preferably, the dissolution time in water for the presently contemplated dosage forms is about 3 minutes to about 5 minutes.
  • the present invention is illustrated further by the following studies which were focused on two specific objectives.
  • the first was to determine whether, relative to placebo response, patients who presented with "psychogenic" impotence (i.e., patients who were still capable of achieving erections) demonstrated improved erectile function and/or enhanced sexual desire post-dosing with sublingual apomorphine (APO).
  • the second objective was to determine what dose(s) of various forms of sublingual APO are effective in this group of patients for inducing an erection that is sufficient for vaginal penetration.
  • Participating patients were selected from among those that initially presented with the complaint of impotence. These patients underwent a thorough urological assessment by a urologist as well as an assessment by a psychiatrist. Diagnostic testing for erectile difficulties was extensive and included the following: biochemical profile, nocturnal penile tumescence (NPT) monitoring, doppler flow studies, biothesiometry, corporal calibration testing with an intracorporal injection of triple therapy and dynamic cavernosometry. These tests were used to rule out any arterial, venous or peripheral neural causality of impotence. Any patients with abnormalities in any of these three areas were excluded from entry to the trials. The inclusion/exclusion criteria for all four pilot studies are set forth in Table V, below. Patients who met all criteria were diagnosed as having impotence primarily of a psychogenic origin. If there were no known medical contraindications to the use of a dopaminergic medication they were offered entry into an APO trial.
  • a RIGISCANTM ambulatory tumescence monitor (Dacomed Corp., Minneapolis, Minn.) was placed on the patient and the computer was set in the real time monitoring mode. Blood pressure and heart rate were recorded pre-dosing with APO or placebo and at the end of the testing session. Visual analogue scales (VAS) were completed by the patient pre-dosing as well as post-dosing (at the end of the testing session). These scales reflected the patient's sense of well being, level of sedation, tranquilization, anxiousness, arousal and any changes in yawning behavior. In a single-blind fashion, apomorphine or placebo was administered to the patient sublingually.
  • VAS Visual analogue scales
  • Symptoms as they were volunteered were recorded by the research clinician. If the patient complained of nausea or felt unwell in any way he was asked if he wanted to abort the trial. If the trial was aborted, the patient was given Gravol 50 mg p.o. at that time. The patient was monitored by the research clinician until these side-effects had subsided. He was asked to return the following week for retesting at the same dose and was instructed to begin treatment with Domperidone 10 m.g. p.o. TID the day before and morning of his next session.
  • Visual analogue scales (See Table IX) were compared both pre- and post-dosing, and examined for changes in feeling of well being, levels of arousal, anxiousness, sedation/tranquilization and yawning behavior. Blood pressure and heart rate were also compared pre- and post-dosing.
  • Adverse Effects i.e., flushing, diaphoresis, nausea, vomiting, changes in blood pressure or heart rate
  • Primary Effects i.e., yawning and erections
  • the initial formulation evaluated was liquid apomorphine administered via sublingual route.
  • APO was prepared by a clinic pharmacist and dissolved in a solution of sodium metabisulfite and ethylenediamine tetraacetic acid (EDTA). The final concentration was 100 mg/ml. Patients were tested on three separate occasions at three separate doses (placebo; 10 mg; 20 mg)
  • Apomorphine is effective in inducing erectile episodes without increasing libido in the "psychogenically" impotent male.
  • the first sublingual tablet formulations evaluated were 2.5 and 5 mg. Patients were tested on three separate occasions at three separate doses (placebo; 2.5 mg, 5 mg).
  • the primary effect of yawning was both reported by patients and observed at both 2.5 mg and 5 mg doses.
  • the incidence of yawning increased between fifteen and forty minutes post-dosing.
  • All patients who failed testing had only one or two yawns per session.
  • the 5 mg dose not only produced adverse effects (nausea, diaphoresis, dizziness, blurred vision, facial flushing, drop in both heart rate and blood pressure) but also increased yawning responses to three to five times per session.
  • the two successful patients experienced three to five yawns at both the 2.5 mg and 5 mg doses. These changes were not evident with placebo.
  • the 5 mg dose can produce adverse effects (i.e., nausea, diaphoresis, etc.) that may be unacceptable to patients and their partners. These effects can be counteracted with the administration of Domperidone or nicotine (e.g., by smoking).
  • the sublingual tablets were easy to administer and dissolved within five minutes.
  • Apomorphine was evaluated as an aqueous intranasal spray (1.25 mg per puff). The first patient was an anxious, 53 year old male who had been experiencing erectile dysfunction for two years. This patient had previously failed a trial of yohimbine.
  • Patient No. 2 was twenty-one year old male with erectile problems of a duration of three years. He had failed a previous course of yohimbine HCl. Ten minutes post-dosing with apomorphine at 2.5 mg he experienced yawing for a total of five yawns, and then experienced immediately major hemodynamic adverse effects. These included pale and ashen coloring, diaphoresis, nausea and vomiting, blurred vision, hypotension with a blood pressure of 70/50. Twenty minutes post adverse effect, vital signs were stable. The patient was feeling well, and coloring was good. This patient was then dropped from further testing.
  • Pilot Study #4 The data of Pilot Study #4 were analyzed in two ways. First, mean erectile function was compared across placebo, 3 mg and 4 mg doses under two stimulus backgrounds, erotic and neutral. Next erectile function scores were dichotomized, with values less than sixteen considered to reflect erectile insufficiency.
  • Table VIII A shows means and standard errors for all three treatments under both backgrounds, erotic and neutral. Means were compared using a restricted maximum likelihood generalized linear model containing two main effects, treatment and stimulus, and the treatment by stimulus interaction. An appropriate variance-covariance structure was established for the underlying statistical model using Akaike's criterion. Table VIII B presents the statistical results for the main effects of treatment and of stimulus, for the treatment by stimulus interaction, and for orthogonal contrasts within the erotic and neutral conditions. It can be seen that the treatment main effect (i.e., general difference across treatment conditions without regard to stimulus background) is statistically significant; that the main effect of stimulus (i.e., general difference across stimulus backgrounds without regard to treatment) is statistically significant; and that the treatment by stimulus interaction is not statistically significant.
  • the treatment main effect i.e., general difference across treatment conditions without regard to stimulus background
  • the main effect of stimulus i.e., general difference across stimulus backgrounds without regard to treatment
  • the treatment by stimulus interaction is not statistically significant.
  • FIG. 2 and Table VIII C show that the statistically significant superiority of active over placebo treatment, regardless of stimulus background, is maintained when the erectile function scores are classified to reflect success (score at least 16) or failure (score less than 16).
  • Clinical response to sublingual administration of apomorphine was evaluated utilizing a group of 60 non-vasculogenic impotent patients. Each patient had a history of erectile dysfunction for at least 3 months, normal biothesiometry response, and normal cavernosometry results.
  • the patients were divided into seven groups. Each group received a predetermined dosage of apomorphine for 20 days in the form of apomorphine hydrochloride tablets 20 minutes prior to intercourse. Seven different dosages were evaluated--3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg and 10 mg The tablet constituents were those shown in Table I, above. Assessment of response was made on the basis of the patient's report of his experience. A response was deemed positive when the patient experienced an erection sufficiently rigid to effect penetration. Side effects such as nausea and/or vomiting, if present, were noted as well.
  • the aforesaid apomorphine dosage forms are also well suited for diagnosing male human patients suffering from male erectile dysfunction.
  • at least about 3 milligrams of apomorphine are administered sublingually to the patient and the patient is exposed to a visual erotic stimulus, e.g., an erotic videotape, while the patient's response thereto is monitored. If deemed desirable for diagnostic purposes, up to about 10 milligrams of apomorphine can be administered to the patient.
  • the patient's maximum increase in penile circumference is determined and the patient's maximum penile rigidity (preferably tip as well as basal) is determined.
  • the determined circumferential increase and rigidity values are then compared against a predetermined base value. Equivalent methods of determining tumescence and rigidity can also be utilized.
  • the study population was seven healthy, Caucasian male volunteers between 18 and 35 years of age.
  • Three doses (one intravenous; 2 sublingual) were administered to each subject in random order 4 days apart.
  • Pharmacokinetic analysis was performed by compartmental and noncompartmental methods described below.
  • Nonlinear, iterative, least-squares regression analysis was performed with the computer program, PPHARM (Simed Co., Philadelphia, Pa.).
  • the apomorphine plasma concentration data for each subject following intravenous administration was fitted to two-compartment open model with a first order input function as described by the following equations.
  • Plasma apomorphine concentration was described for intravenous administration data by equation (1):
  • Plasma apomorphine concentration was described for sublingual tablet administration by equations (2) and (3): ##EQU1##
  • C t is the apomorphine plasma concentration at time t
  • F is the relative bioavailability, which is assumed to be one for intravenous administration
  • K a is the first order rate constant for sublingual absorption
  • K e is the first order rate constant for elimination
  • V d is the volume of distribution
  • D is the apomorphine dose
  • t is time
  • t lag is the lag time before onset of sublingual absorption
  • A, B, C are the intercepts of the distribution, elimination, and absorption phases, respectively
  • ⁇ is the distribution rate constant
  • ⁇ is the elimination rate constant
  • K a is the absorption rate constant.
  • the regression analysis provided the final estimates of the pharmacokinetic parameters: V d , K e , K a , and t lag from equation (2), and A, B, C, ⁇ , ⁇ , k a , and t lag from equation (3).
  • the maximum plasma concentration (C max ) , time to maximum plasma concentration (T max ) , and V d (volume of distribution) were calculated using standard compartmental pharmacokinetic equations (Gibaldi, M. & Perrier, D. Pharmacokinetics, 2d edition, Marcel Dekker, Inc. New York, 1982).
  • the K e was determined by linear regression analysis of the log plasma concentration versus time during the post-absorption phase. Estimates of noncompartmental parameters C max and T max were obtained from visual inspection of the plasma concentration time curves.
  • ANOVA analysis of variance
  • a clinical study of patient tolerance of escalating doses in sublingual tablet administration of APO for the treatment of psychogenic male erectile dysfunction was performed.
  • the pilot study compared the effects of sublingual tablet administration of placebo, and 4, 6 and 8 mg apomorphine hydrochloride (APO) on male erectile dysfunction as measured by RigiscanTM monitoring and self-reported satisfaction with the treatment results.
  • APO apomorphine hydrochloride
  • MED men with psychogenic male erectile dysfunction
  • VAS visual analogue scale questionnaire
  • the third phase a home-use phase, lasted 5 weeks. During this phase, subjects attempted coitus at least once each week after taking a single APO tablet. After each attempt the subject and his partner completed a Sexual Function questionnaire (Table XVI). Subjects had a final evaluation at the end of the 5-week, home-use phase.
  • hypotension was reported as an adverse event in some subjects in this study, along with bradycardia, dizziness, syncope, and pallor. Only single cases of hypotension and pallor were judged severe in this study. Increased sweating and fatigue were also reported. One of the cases of increased sweating was considered severe. The other severe adverse events (mouth edema, dysphagia, upper respiratory tract infection) were judged unrelated to treatment.
  • APO efficacy of APO was evaluated during the first two phases of the study in which subjects were attached to the RigiscanTM monitor. Subjects were initially treated with placebo in the first phase. In the second phase, patients received 4, 6 and 8 mg APO tablets with a placebo tablet randomly interspersed in the treatment.
  • the success rate showed numerical increase at tablet strength from 4 mg to 6 mg, but a decrease at 8 mg (TABLE XX).
  • the highest success rate was 73% in both males and females at a tablet strength of 6 mg (TABLE XX).
  • a dosage range of 50-74 ⁇ g/kg gave the highest success rate(: 82%) in females and (80%) in males (Table XXI).
  • the dosage range of 35-50 ⁇ g/kg gave the highest success rate.

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Abstract

Psychogenic impotence or erectile dysfunction can be identified in psychogenic male patients and can be ameliorated, without substantial undesirable side effects, by sublingual administration of apomorphine dosage forms so as to maintain a plasma concentration of apomorphine of no more than about 5.5 nanograms per milliliter.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
This application is a continuation in part of U.S. Ser. No.08/231,250 filed on Apr. 22, 1994, now abandoned.
FIELD OF THE INVENTION
This invention, in one aspect, relates to dosage forms and methods for ameliorating erectile dysfunction in psychogenic male patients. In another aspect this invention relates to diagnosis of erectile dysfunction. More particularly, this invention relates to the use of apomorphine-containing compositions for amelioration of erectile dysfunction in psychogenic male patients and for diagnostic purposes.
BACKGROUND OF THE INVENTION
A normal erection occurs as a result of a coordinated vascular event in the penis. This is usually triggered neurally and consists of vasodilation and smooth muscle relaxation in the penis and its supplying arterial vessels. Arterial inflow causes enlargement of the substance of the corpora cavernosa. Venous outflow is trapped by this enlargement, permitting sustained high blood pressures in the penis sufficient to cause rigidity. Muscles in the perineum also assist in creating and maintaining penile rigidity. Erection may be induced centrally in the nervous system by sexual thoughts or fantasy, and is usually reinforced locally by reflex mechanisms. Erectile mechanics are substantially similar in the female for the clitoris.
Impotence or male erectile dysfunction is defined as the inability to achieve and sustain an erection sufficient for intercourse. Impotence in any given case can result from psychological disturbances (psychogenic), from physiological abnormalities in general (organic), from neurological disturbances (neurogenic), hormonal deficiencies (endocrine) or from a combination of the foregoing.
These descriptions are not exact, however. There is currently no standardized method of diagnosis or treatment. As used herein, psychogenic impotence is defined as functional impotence with no apparent overwhelming organic basis. It may be characterized by an ability to have an erection in response to some stimuli (e.g., masturbation, spontaneous nocturnal, spontaneous early morning, video erotica, etc.) but not others (e.g., partner or spousal attention).
Various methods for the treatment of impotence have been suggested, including external devices, for example, tourniquets (see U.S. Pat. No. 2,818,855). In addition, penile implants, such as hinged or solid rods and inflatable, spring driven or hydraulic models, have been used for some time. The administration of erection effecting and enhancing drugs is taught in U.S. Pat. No. 4,127,118 to LaTorre. That patent teaches a method of treating male impotence by injecting into the penis an appropriate vasodilator, in particular, an adrenergic blocking agent or a smooth muscle relaxant to effect and enhance an erection. More recently, U.S. Pat. No. 4,801,587 to Voss et al. teaches the application of an ointment to relieve impotence. The ointment consists of the vasodilators papaverine, hydralazine, sodium nitroprusside, phenoxybenzamine, or phentolamine and a carrier to assist absorption of the primary agent through the skin. U.S. Pat. No. 5,256,652 to El-Rashidy teaches the use of an aqueous topical composition of a vasodilator such as papaverine together with hydroxypropyl-β-cyclodextrin.
Recently the effect of apomorphine on penile tumescence in male patients afflicted with psychogenic impotence has been studied. These studies show that while apomorphine can indeed induce an erection in a psychogenic male patient, the apomorphine dose required to achieve a significant erectile response is usually accompanied by nausea or other serious undesirable side effects such as hypertension, flushing and diaphoresis. The specific mechanisms by which apomorphine acts to produce an erectile response in a human patient are not yet completely understood, however.
Moreover, apomorphine has been shown to have very poor oral bioavailability. See, for example, Baldessarini et al., in Gessa et al., eds., Apomorphine and Other Dopaminomimetics, Basic Pharmacology, Vol. 1, Raven Press, N.Y. (1981), pp. 219-228.
Thus the search is continuing for an effective treatment of psychogenic impotence in male patients as well as for diagnostic methods that can identify such patients. It has now been found that certain delivery systems for apomorphine can provide a practical therapeutic and/or diagnostic "window" while reducing the likelihood of undesirable side effects.
SUMMARY OF THE INVENTION
It has now been found that, for an optimal erectile response, steady state circulating serum and mid-brain tissue levels of apomorphine are to be maintained within a relatively closely defined range.
Sublingual apomorphine dosage forms, usually containing about 2.5 to about 10 milligrams of apomorphine, have been found to be effective in male patients suffering from psychogenic erectile dysfunction for the induction and maintenance of an erection sufficient for intercourse (i.e., vaginal penetration) without nausea or other undesirable side effects. The apomorphine is administered sublingually, preferably about 15 to about 20 minutes prior to sexual activity, and so as to maintain a predetermined circulating serum levels and mid-brain tissue levels of apomorphine during the period of sexual activity sufficient to induce an erection adequate for vaginal penetration but less than the amount that induces nausea. The plasma concentration of apomorphine should be maintained at no more than about 5.5 nanograms per milliliter, preferably about 0.3 to about 4 nanograms per milliliter, and more preferably about 1 to about 2 nanograms per milliliter.
The foregoing sublingual apomorphine dosage forms are also suitable for screening patients complaining of erectile dysfunction so as to identify patients of psychogenic etiology.
BRIEF DESCRIPTION OF THE DRAWINGS
In the drawings,
FIG. 1 is a graphical representation of mean erectile function, expressed as RIGISCAN™ monitor value, as a function of apomorphine dose;
FIG. 2 is a bar graph depicting the percent successful erectile function for placebo, 3-milligram apomorphine dose, and 4-milligram apomorphine dose under erotic and neutral conditions;
FIG. 3 is a bar graph presenting yet another comparison of erectile function noted in Pilot Study #4 in terms of RIGISCAN™ monitor score versus placebo, 3 milligrams of apomorphine and 4 milligrams of apomorphine under erotic and neutral conditions; and
FIG. 4 is a graphical representation of a comparison of the plasma concentration time profiles of apomorphine after intravenous administration at a dose of 1 mg (open circles, n=7), sublingual administration at a dose of 4 mg (open squares, n=4) and sublingual administration at a dose of 8 mg (half-filled squares, n=4).
DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS
Apomorphine is a dopamine receptor agonist that has a recognized use as an emetic when administered subcutaneously in about a 5-milligram dose. For the purposes of the present invention, apomorphine or a similarly acting dopamine receptor agonist is administered in an amount sufficient to excite cells in the mid-brain region of the patient but with minimal side effects. This cell excitation is believed to be part of a cascade of stimulation that is likely to include neurotransmission with serotonin and oxytocin.
The dopamine receptors in the mid-brain region of a patient can be stimulated to a degree sufficient to cause an erection by the sublingual administration of apomorphine so as to maintain a plasma concentration of apomorphine of no more than about 5.5 nanograms per milliliter (5.5 ng/ml). The sublingual administration usually takes place over a time period in the range of about 2 to about 10 minutes, or longer. The amount of apomorphine administered sublingually over this time period preferably is in the range of about 25 micrograms per kilogram (μg/kg) of body weight to about 60 μg/kg of body weight.
The apomorphine is administered preferably about 15 to about 20 minutes prior to sexual activity.
Apomorphine can be represented by the formula ##STR1## and exists in a free base form or as an acid addition salt. For the purposes of the present invention apomorphine hydrochloride is preferred; however, other pharmacologically acceptable moieties thereof can be utilized as well. The term "apomorphine" as used herein includes the free base form of this compound as well as the pharmacologically acceptable acid addition salts thereof. In addition to the hydrochloride salt, other acceptable acid addition salts are the hydrobromide, the hydroiodide, the bisulfate, the phosphate, the acid phosphate, the lactate, the citrate, the tartarate, the salicylate, the succinate, the maleate, the gluconate, and the like.
Illustrative preferred sublingual dosage forms are set forth in Table I, below.
              TABLE I                                                     
______________________________________                                    
150-Milligram Apomorphine Hydrochloride Sublingual Tablets                
______________________________________                                    
3-mg Tablet                                                               
Apomorphine Hydrochloride                                                 
                       2.00   wt-%                                        
Mannitol               66.67  wt-%                                        
Ascorbic Acid          3.33   wt-%                                        
Citric Acid            2.00   wt-%                                        
Avicel PH102           15.00  wt-%                                        
Methocel E4M           10.00  wt-%                                        
Aspartame              0.67   wt-%                                        
Magnesium Stearate     0.33   wt-%                                        
4-mg Tablet                                                               
Apomorphine Hydrochloride                                                 
                       2.66   wt-%                                        
Mannitol               66.00  wt-%                                        
Ascorbic Acid          3.33   wt-%                                        
Citric Acid            2.00   wt-%                                        
Avicel PH102           15.00  wt-%                                        
Methocel E4M           10.00  wt-%                                        
Aspartame              0.67   wt-%                                        
Magnesium Stearate     0.33   wt-%                                        
5-mg Tablet                                                               
Apomorphine Hydrochloride                                                 
                       3.33   wt-%                                        
Mannitol               65.34  wt-%                                        
Ascorbic Acid          3.33   wt-%                                        
Citric Acid            2.00   wt-%                                        
Avicel PH102           15.00  wt-%                                        
Methocel E4M           10.00  wt-%                                        
Aspartame              0.67   wt-%                                        
Magnesium Stearate     0.33   wt-%                                        
______________________________________
If desired, and in order to facilitate absorption and thus bioavailability, the presently contemplated dosage forms can also contain, in addition to tabletting excipients, β-cyclodextrin or a β-cyclodextrin derivative such as hydroxypropyl-β-cyclodextrin (HPBCD). Illustrative dosage forms containing HPBCD are shown in Tables II and III, below.
              TABLE II                                                    
______________________________________                                    
Apomorphine Hydrochloride Sublingual Tablets                              
With Hydroxypropyl-β-Cyclodextrin                                    
                    mg/Tab                                                
______________________________________                                    
Apomorphine Hydrochloride                                                 
                    4.0                                                   
HPBCD               5.0                                                   
Ascorbic Acid       10.0                                                  
PEG 8000            39.5                                                  
Mannitol            39.5                                                  
Aspartame           2.0                                                   
TOTAL               100.0                                                 
______________________________________                                    

              TABLE III                                                   
______________________________________                                    
Apomorphine Hydrochloride Sublingual                                      
Tablets With β-Cyclodextrin                                          
                     mg/Tab                                               
______________________________________                                    
Apomorphine Hydrochloride                                                 
                     5.0                                                  
β-Cyclodextrin  20.0                                                 
Ascorbic Acid        5.0                                                  
Mannitol             68.9                                                 
Magnesium Stearate   1.0                                                  
D&C Yellow 10 Aluminum Lake                                               
                     0.1                                                  
TOTAL                100.0                                                
______________________________________
The onset of nausea can be obviated or delayed by delivering apomorphine at a controlled dissolution rate so as to provide circulating serum levels and mid-brain tissue levels of apomorphine sufficient for an erection without inducing nausea. When apomorphine is administered at or near the relatively higher amounts of the aforementioned dosage range, the likelihood of nausea onset can be reduced by concurrent administration of a ganglionic agent (inhibitor of ganglionic response) such as nicotine or lobeline sulfate. For this purpose, the weight ratio of apomorphine to ganglionic agent is in the range of about 10 to about 1.
Other antiemetic agents that can be used in conjunction with apomorphine are antidopaminergic agents such as metoclopramide, and the phenothiazines, e.g., chlorpromazine, prochlorperazine, pipamazine, thiethylperazine, oxypendyl hydrochloride, and the like. Also suitable are the serotonin (5-hydroxytryptamine or 5-HT) antagonists such as domperidone, odansetron (commercially available as the hydrochloride salt under the designation Zofran®), and the like, the histamine antagonists such as buclizine hydrochloride, cyclizine hydrochloride, dimenhydrinate (Dramamine), and the like, the parasympathetic depressants such as scopolamine, and the like, as well as other anti-emetics such as metopimazine, trimethobenzamide, benzquinamine hydrochloride, diphenidol hydrochloride, and the like.
Nicotine-containing dosage forms and domperidone-containing dosage forms are illustrated in Table IV, below.
              TABLE IV                                                    
______________________________________                                    
Apomorphine Hydrochloride Sublingual Tablets                              
Containing an Anti-Emetic Agent                                           
                     mg/Tab                                               
______________________________________                                    
Apomorphine Hydrochloride                                                 
                     5.0                                                  
Ascorbic Acid        5.0                                                  
Mannitol             67.9                                                 
Magnesium Stearate   1.0                                                  
Nicotine             1.0                                                  
β-Cyclodextrin  20.0                                                 
D&C Yellow 10 Aluminum Lake                                               
                     0.1                                                  
TOTAL                100.0                                                
______________________________________                                    
Apomorphine Hydrochloride                                                 
                     5.0                                                  
Ascorbic Acid        5.0                                                  
Mannitol             58.9                                                 
Magnesium Stearate   1.0                                                  
Domperidone          10.0                                                 
β-Cyclodextrin  20.0                                                 
D&C Yellow 10 Aluminum Lake                                               
                     0.1                                                  
TOTAL                100.0                                                
______________________________________
The preferred sublingual dosage forms dissolve within a time period of at least about 2 minutes but less than about 10 minutes. The dissolution time can be longer, however, if desired as long as the necessary plasma concentration of apomorphine can be maintained. More preferably, the dissolution time in water for the presently contemplated dosage forms is about 3 minutes to about 5 minutes.
The present invention is illustrated further by the following studies which were focused on two specific objectives. The first was to determine whether, relative to placebo response, patients who presented with "psychogenic" impotence (i.e., patients who were still capable of achieving erections) demonstrated improved erectile function and/or enhanced sexual desire post-dosing with sublingual apomorphine (APO). The second objective was to determine what dose(s) of various forms of sublingual APO are effective in this group of patients for inducing an erection that is sufficient for vaginal penetration.
Participating patients were selected from among those that initially presented with the complaint of impotence. These patients underwent a thorough urological assessment by a urologist as well as an assessment by a psychiatrist. Diagnostic testing for erectile difficulties was extensive and included the following: biochemical profile, nocturnal penile tumescence (NPT) monitoring, doppler flow studies, biothesiometry, corporal calibration testing with an intracorporal injection of triple therapy and dynamic cavernosometry. These tests were used to rule out any arterial, venous or peripheral neural causality of impotence. Any patients with abnormalities in any of these three areas were excluded from entry to the trials. The inclusion/exclusion criteria for all four pilot studies are set forth in Table V, below. Patients who met all criteria were diagnosed as having impotence primarily of a psychogenic origin. If there were no known medical contraindications to the use of a dopaminergic medication they were offered entry into an APO trial.
Instructions were given regarding the protocol by the research clinician, and an informed consent was obtained. Patients were advised that they were free to withdraw from the trial at any time without penalty or prejudice. They were tested on at least three separate days at three separate doses (placebo and two active medication doses) with an interval of no less than three days between. The experimental scheme described below was used in all four pilot studies.
Patients were seated in a comfortable chair and a RIGISCAN™ ambulatory tumescence monitor (Dacomed Corp., Minneapolis, Minn.) was placed on the patient and the computer was set in the real time monitoring mode. Blood pressure and heart rate were recorded pre-dosing with APO or placebo and at the end of the testing session. Visual analogue scales (VAS) were completed by the patient pre-dosing as well as post-dosing (at the end of the testing session). These scales reflected the patient's sense of well being, level of sedation, tranquilization, anxiousness, arousal and any changes in yawning behavior. In a single-blind fashion, apomorphine or placebo was administered to the patient sublingually. Doses of active medication varied on the formulation of the apomorphine administered (liquid or tablet). Because of the possibility of nausea and the tolerance to this effect that prior dosing conveys, the patient was given increasing doses at each testing. However, the patient was unaware of the dose that he was receiving (single-blind). Patients were instructed not to swallow the medication, but to keep it under their tongue and allow it to be absorbed there.
Symptoms as they were volunteered were recorded by the research clinician. If the patient complained of nausea or felt unwell in any way he was asked if he wanted to abort the trial. If the trial was aborted, the patient was given Gravol 50 mg p.o. at that time. The patient was monitored by the research clinician until these side-effects had subsided. He was asked to return the following week for retesting at the same dose and was instructed to begin treatment with Domperidone 10 m.g. p.o. TID the day before and morning of his next session.
Patients not experiencing nausea or any other significant adverse effects within fifteen minutes post-dosing with APO or placebo viewed segments of standardized erotic videos to provide sexual stimulation. The following sequence of videos was viewed: a ten minute erotic video, a neutral video lasting between five and ten minutes in duration and finally another ten minute erotic video. The duration of the testing session for each dose level lasted between 45 and 60 minutes. After determining the most effective dose of apomorphine for the patient, he was then offered APO for domestic trial at that dose.
Results of Pilot Studies 1 to 4
The frequency and the magnitude of erectile responses were documented with each dose of apomorphine or placebo. Data obtained from the RIGISCAN™ monitor was downloaded and each session was scanned. Erection responses were then scored for rigidity (%) and tumescence (cm.) at both the tip and base of the penis and an overall score was given that corresponded to these parameters during the viewing of both erotic and neutral video segments (see Table VI, below). A score of less than 16 indicated erectile dysfunction and a poor response to apomorphine at that dose.
Visual analogue scales (See Table IX) were compared both pre- and post-dosing, and examined for changes in feeling of well being, levels of arousal, anxiousness, sedation/tranquilization and yawning behavior. Blood pressure and heart rate were also compared pre- and post-dosing.
Effects of apomorphine that were both reported to and observed by the research clinician were grouped into two categories: Adverse Effects (i.e., flushing, diaphoresis, nausea, vomiting, changes in blood pressure or heart rate) or Primary Effects (i.e., yawning and erections).
Each pilot study was reviewed under the categories mentioned above.
Pilot Study #1
The initial formulation evaluated was liquid apomorphine administered via sublingual route. APO was prepared by a clinic pharmacist and dissolved in a solution of sodium metabisulfite and ethylenediamine tetraacetic acid (EDTA). The final concentration was 100 mg/ml. Patients were tested on three separate occasions at three separate doses (placebo; 10 mg; 20 mg)
Twelve patients entered into this trial. All patients had reported erectile dysfunction greater than 1 year in duration. The age range in this group was from 38 to 60 years. One patient withdrew after placebo and another withdrew after adverse effects at the 20 mg dose. That left a total evaluable group of ten. All ten patients had previously received yohimbine HCl for erectile dysfunction. Eight had failed a trial of yohimbine HCl. Of this group of eight, 6 were successful with apomorphine.
Seven (70%) were success (score of no less than 16 on both neutral and erotic video segments; Table VI) and three (30%) were categorized as failures with apomorphine. Six out of the seven successful patients continued on with a domestic trial of apomorphine at the dose that gave them the best response during testing. Three required treatment with Domperidone the day before and morning of apomorphine usage. The range of domestic use varied from two to seven months.
Analysis of visual analogue scales pre- and post-dosing with apomorphine indicated the following. At the end of the session patients were relaxed but not sedated. There was no evidence of arousal or anxiousness. Yawning behavior changes were evident on these scales with the incidence of yawning increasing between 15 and fifty minutes post-dosing and with each increase in dosing. Each patient experienced between two to five yawns per session. These changes were not evident with placebo.
The primary effect of yawning was both reported by patients and observed at both 10 mg and 20 mg doses. No yawning was reported with placebo. Adverse effects were reported at both dose levels. Two patients who did not experience nausea or diaphoresis were researched for similarities in their patient profiles but none were found. Anywhere from ten to fifteen minutes post-dosing the other eight patients developed sudden onset of various levels of nausea (and in one instance vomiting), diaphoresis, dizziness, double or blurred vision, decrease in both blood pressure and heart rate and pale or ashen coloring. Side effects varied from being transient and brief to lasting as long as from 30 to 40 minutes. One patient reported a stuffy nose starting approximately 30 minutes post-dosing and lasting for approximately 10 minutes. No adverse effects were reported post placebo dosing.
The foregoing Pilot Study leads to the following conclusions:
1. Apomorphine is effective in inducing erectile episodes without increasing libido in the "psychogenically" impotent male.
2. Both 10 mg and 20 mg doses produce erectile responses.
3. Both doses produced adverse effects (nausea, vomiting, diaphoresis, etc.) that would be unacceptable to patients and their partners, however. These effects can be counteracted with the use of Domperidone.
Pilot Study #2
The first sublingual tablet formulations evaluated were 2.5 and 5 mg. Patients were tested on three separate occasions at three separate doses (placebo; 2.5 mg, 5 mg).
A total of eight patients entered into this trial. All patients reported erectile difficulties for more that two years. The age range was from 38 to 62 years. All had failed a trial of yohimbine HCl. One patient withdrew from the trial after experiencing adverse effects at the 5 mg dose. That left a total of seven evaluable patients.
Two (29%) were successes (score of no less than 16; Table VI) and five (71%) were failures during lab testing. The two successful patients went onto a domestic trial of apomorphine at the 2.5 mg dose which was the most effective and did not produce adverse effects. Both patients used apomorphine at home for no less than two months with satisfactory results.
Analysis of visual analogue scales pre- and post-dosing with apomorphine indicated the same trends as with the liquid apomorphine preparation. Patients were relaxed but not sedated. No evidence of arousal or anxiousness was noted.
The primary effect of yawning was both reported by patients and observed at both 2.5 mg and 5 mg doses. The incidence of yawning increased between fifteen and forty minutes post-dosing. At the 2.5 mg dose all patients who failed testing had only one or two yawns per session. The 5 mg dose not only produced adverse effects (nausea, diaphoresis, dizziness, blurred vision, facial flushing, drop in both heart rate and blood pressure) but also increased yawning responses to three to five times per session. The two successful patients experienced three to five yawns at both the 2.5 mg and 5 mg doses. These changes were not evident with placebo.
At the end of Pilot Study #2 the following conclusions were made:
1. There appears to be a correlation between the effectiveness of the dose and yawning response (poor responders experience less yawning).
2. Both 2.5 and 5 mg doses produced erectile responses in some patients. The apparent 28% success rate was because of lab use only (failures were not given drug to take home) and lack of available intermediate doses.
3. In some instances the 5 mg dose can produce adverse effects (i.e., nausea, diaphoresis, etc.) that may be unacceptable to patients and their partners. These effects can be counteracted with the administration of Domperidone or nicotine (e.g., by smoking).
4. The sublingual tablets were easy to administer and dissolved within five minutes.
Pilot Study #3
Apomorphine was evaluated as an aqueous intranasal spray (1.25 mg per puff). The first patient was an anxious, 53 year old male who had been experiencing erectile dysfunction for two years. This patient had previously failed a trial of yohimbine.
He was tested on three separate occasions at three separate doses (placebo, 2.5 mg; 3.75 mg) and was categorized as a failure with the score of less than sixteen on both erotic and neutral video segments. He experienced yawning with both 2.5 mg and the 3.75 mg and was successful with this trial for two months until he inadvertently increased the dose. Adverse effects occurred within five minutes post-dosing (nausea and vomiting, dizziness, double and blurred vision, diaphoresis, and ashen coloring). The patient refused to retry medication after this incident. He stated he did not like this formulation.
Patient No. 2 was twenty-one year old male with erectile problems of a duration of three years. He had failed a previous course of yohimbine HCl. Ten minutes post-dosing with apomorphine at 2.5 mg he experienced yawing for a total of five yawns, and then experienced immediately major hemodynamic adverse effects. These included pale and ashen coloring, diaphoresis, nausea and vomiting, blurred vision, hypotension with a blood pressure of 70/50. Twenty minutes post adverse effect, vital signs were stable. The patient was feeling well, and coloring was good. This patient was then dropped from further testing.
Although the intranasal administration was effective in eliciting an erection, further testing of this intranasal formulation of apomorphine was discontinued because of possible overdose and increased side effects. The foregoing experience illustrates the need for reliable and relatively safer dosage forms, however.
Pilot Study #4
New sublingual tablet formulations of apomorphine at 3, 4 and 5 mg doses (Table I, above) were evaluated. Patients were tested on at least three separate occasions on at least three separate doses (placebo; 3 mg; and 4 mg). A 5 mg sublingual dose was also tested in some patients. The results of this study are summarized in Tables VII and VIII A-C, below.
To date, twelve patients have been completely evaluated on this formulation. All patients reported erectile dysfunction for more than two years. The patients' age range was thirty-nine to sixty-six years. Three patients had been successful with yohimbine HCl in the past, and two had previously not tried this compound. Seven patients of this group of twelve had previously failed a trial of yohimbine HCl. Of this latter group of seven, four were successfully treated with apomorphine.
Eight (67%) have been successful with apomorphine to date. Four (33%) were failures with apomorphine. Both 3 mg and 4 mg doses produced erectile responses. Several patients went on to a trial of the 5 mg sublingual dose which did not appear to be more effective than the relatively lesser doses in terms of erectile response. All eight of the successful patients continued on with the domestic use for a time period of one to four months. All patients reported good erectile activity and no side effects.
Analysis of visual analogue scales, both pre- and post-dosing with apomorphine, again indicated that the patients were relaxed but not sedated, and did not have feelings of arousal or anxiousness post-dosing. The new formulations tested (3 mg; 4 mg; and 5 mg) were devoid of adverse effects. The patients felt well post testing, and did not report or demonstrate any adverse effects that had traditionally been seen with the administration of previous apomorphine liquid and intranasal preparations (Pilot Studies No. 1 and No. 3). The primary effect of yawning was still reported and observed at all doses, but the number and frequency of yawns was small (one or two).
The foregoing pilot study shows that 3-mg, 4-mg and 5-mg apomorphine doses are effective in inducing penile erections, and also that there are no serious adverse effects with these preparations. Domestic use of these preparations was well accepted by patients and their partners. They were content with the convenience of dosing approximately fifteen minutes prior to sexual activity. All patients have stated that this was more acceptable than dealing with dosing on a routine basis.
              TABLE V                                                     
______________________________________                                    
Inclusion/Exclusion Criteria                                              
______________________________________                                    
INCLUSION CRITERIA:                                                       
1.     Age 18-66 years.                                                   
2.     NPT circumference increase of 1.5 cm or more on one                
       night and >70% rigidity.                                           
3.     ICI circumference increase of 1.5 cm or more and >70%              
       rigidity.                                                          
EXCLUSION CRITERIA:                                                       
1.     Currently severe or life threatening systemic disease.             
2.     Clinically significant ECG abnormalities.                          
3.     Personal or first degree family history of epilepsy.               
4.     Abnormal: Hepatic/renal function                                   
       Hematology                                                         
5.     Low: pre-trial testosterone                                        
       Low or High: LH                                                    
       High: Prolactin                                                    
6.     Hypertension requiring treatment.                                  
7.     History of depression requiring treatment with                     
       antidepressants, ECT, or hospitalization.                          
8.     Symptomatic ischemic heart disease/or MI within the last           
       three months.                                                      
9.     Diabetes.                                                          
10.    Failure to obtain informed consent.                                
11.    Legal cases.                                                       
12.    Unable or unwilling to comply with protocol.                       
13.    Drinks more than (on average) 45 units alcohol per                 
       week/or uses illicit drugs.                                        
14.    History of syncope.                                                
15.    Prohibited Drugs: sympathetic or parasympathetic types             
       drugs, Beta blockers, Vasodilators, psychotropic                   
       medications, tranquilizers, thiazides, Captopril, Verapmil,        
       Furosemide, Spironolactone, Metochlopramide,                       
       Cimetidine or other drugs which are likely to influence            
       erectile function.                                                 
______________________________________                                    

              TABLE VI                                                    
______________________________________                                    
Response to Erotic Videotape                                              
______________________________________                                    
1.  Maximum increase in penile circumference                              
    Circumference (cms.)      Score                                       
    0-<0.5 cm.                0                                           
    0.5-<1.0 cm.              1                                           
    1.0-<1.5 cm.              2                                           
    1.5-<2.0 cm.              3                                           
    2.0-<2.5 cm. lasts <1 min.                                            
                              4                                           
    2.5 or more lasts <1 min. 5                                           
    2.0-<2.5 cm. lasts at least 1 min.                                    
                              6                                           
    2.5 or more lasts at least 1 min.                                     
                              7                                           
    3.0 or more lasts at least 5 min.                                     
                              8                                           
    3.0 or more lasts at least 10 min.                                    
                              9                                           
                              Score                                       
    A. Maximum increase in penile tip circumference                       
    B. Maximum increase in penile basal circumference                     
2.  Maximum penile rigidity                                               
    Rigidity (%)              Score                                       
    0-<10                     0                                           
    10-<20                    1                                           
    20-<30                    2                                           
    30-<40                    3                                           
    40-<50                    4                                           
    50-<60                    5                                           
    60-<70                    6                                           
    70-<80                    7                                           
    80-<90                    8                                           
    90-100                    9                                           
                              Score                                       
    C. Maximum penile tip rigidity                                        
    D. Maximum penile basal rigidity                                      
3.  Total score (A, B, C & D)                                             
______________________________________                                    
 A score of less than 16 indicates erectile dysfunction                   

                                  TABLE VII                               
__________________________________________________________________________
Summary of Results from Pilot Study #4 in Psychogenic Patients            
                   Apomorphine · HCl Sublingual Tablet           
         PLACEBO   3 Mg Dose (μg/kg)                                   
                             4 Mg Dose (μg/kg)                         
                                       5 Mg Dose (μg/kg)               
Patient # (Wt., kg)                                                       
         Erotic #1                                                        
              Neutral #1                                                  
                   Erotic #2                                              
                        Neutral #2                                        
                             Erotic #3                                    
                                  Neutral #3                              
                                       Erotic #4                          
                                            Neutral #4                    
__________________________________________________________________________
401 (68.5)                                                                
         31   28   29 (44)                                                
                        27 (44)                                           
                             33 (58)                                      
                                  27 (58)                                 
402 (70.3)                                                                
         12    4   12 (43)                                                
                         4 (43)                                           
                             17 (57)                                      
                                   6 (57)                                 
403 (118)                                                                 
         16    4   22* (25)                                               
                         5 (25)                                           
                             22* (34)                                     
                                  25 (34)                                 
404 (83.5)                                                                
         24   10   26* (36)                                               
                        17 (36)                                           
                             25* (48)                                     
                                  17 (48)                                 
405 (78) 11    1   18* (38)                                               
                         6 (38)                                           
                             12 (51)                                      
                                   8 (51)                                 
                                       10 (64)                            
                                             5 (64)                       
406 (80) 14    5   18* (38)                                               
                        17 (38)                                           
                             17* (50)                                     
                                   2 (50)                                 
407 (100)                                                                 
          8    0   18* (30)                                               
                         4 (30)                                           
                             10 (40)                                      
                                   3 (40)                                 
408 (86.2)                                                                
         28   18   32 (35)                                                
                        21 (35)                                           
                             34 (46)                                      
                                  22 (46)                                 
409 (93)  2    0    4 (32)                                                
                         1 (32)                                           
                              8 (43)                                      
                                   6 (43)                                 
                                        5 (54)                            
                                             4 (54)                       
410 (80)  3    0   13 (38)                                                
                        16 (38)                                           
                              8 (50)                                      
                                   7 (50)                                 
411 (98) 13    5   26* (31)                                               
                        23* (31)                                          
                             24* (42)                                     
                                  20 (42)                                 
412 (73)  7    3    7 (41)                                                
                         1 (41)                                           
                             28* (55)                                     
                                  19* (55)                                
__________________________________________________________________________
 *Patients with score higher than 16 (see scoring table) are positive     
 respondents.                                                             
 Out of 12 patients who were treated in this study, 5 showed improvement a
 both 3 mg and 4 mg doses. Two (2) showed response only at one dose.      
 No improvement in clinical response was observed at 5 mg dose.
The data of Pilot Study #4 were analyzed in two ways. First, mean erectile function was compared across placebo, 3 mg and 4 mg doses under two stimulus backgrounds, erotic and neutral. Next erectile function scores were dichotomized, with values less than sixteen considered to reflect erectile insufficiency.
A. Mean Erectile Function
Table VIII A shows means and standard errors for all three treatments under both backgrounds, erotic and neutral. Means were compared using a restricted maximum likelihood generalized linear model containing two main effects, treatment and stimulus, and the treatment by stimulus interaction. An appropriate variance-covariance structure was established for the underlying statistical model using Akaike's criterion. Table VIII B presents the statistical results for the main effects of treatment and of stimulus, for the treatment by stimulus interaction, and for orthogonal contrasts within the erotic and neutral conditions. It can be seen that the treatment main effect (i.e., general difference across treatment conditions without regard to stimulus background) is statistically significant; that the main effect of stimulus (i.e., general difference across stimulus backgrounds without regard to treatment) is statistically significant; and that the treatment by stimulus interaction is not statistically significant. These findings imply that active treatment is more effective than placebo and that this finding, although stronger when using an erotic stimulus, is true regardless of stimulus background (see FIG. 1). The orthogonal (statistically independent) contrasts confirm that active treatment is superior at a statistically significant level under both erotic and neutral conditions, but also indicate that the difference between the 3 mg and 4 mg dose does not exceed that expected by chance for the number of patients (12) used in this study.
B. Percent Successful Erectile Function
FIG. 2 and Table VIII C show that the statistically significant superiority of active over placebo treatment, regardless of stimulus background, is maintained when the erectile function scores are classified to reflect success (score at least 16) or failure (score less than 16).
              TABLE VIII A                                                
______________________________________                                    
Mean and Percent Successful Erectile Function                             
Stimulus  Treatment                                                       
                   N       Mean (SE)                                      
                                   Percent (SE)                           
______________________________________                                    
Erotic    Placebo  12      14.08 (2.69)                                   
                                   33.33 (13.61)                          
          3 mg     12      18.75 (2.51)                                   
                                   66.67 (13.61)                          
          4 mg     12      19.83 (2.67)                                   
                                   66.67 (13.61)                          
Neutral   Placebo  12       6.50 (2.45)                                   
                                   16.67 (10.76)                          
          3 mg     12      11.83 (2.68)                                   
                                   50.00 (14.43)                          
          4 mg     12      13.50 (2.61)                                   
                                   50.00 (14.43)                          
______________________________________                                    
 Note: Mean (SE) from SAS PROC UNIVARIATE. Percent (SE) from SAS PROC     
 CATMOD.                                                                  

              TABLE VIII B                                                
______________________________________                                    
Anova for Mean Erectile Function                                          
EFFECT            DF       F      P-value                                 
______________________________________                                    
Treatment         2.66     11.56  0.0000                                  
Stimulus          1.66     37.14  0.0000                                  
Treatment by Stimulus                                                     
                  2.66     0.10   0.9046                                  
Contrasts                                                                 
Erotic: Placebo vs. Treatment                                             
                  1.66     9.30   0.0033                                  
Erotic: 3 mg vs 4 mg                                                      
                  1.66     0.30   0.5849                                  
Neutral: Placebo vs. Treatment                                            
                  1.66     13.03  0.0006                                  
Neutral: 3 mg vs. 4 mg                                                    
                  1.66     0.71   0.4014                                  
______________________________________                                    
 Note: Restricted maximum likelihood analysis performed using SAS PROC    
 MIXED.                                                                   

              TABLE VIII C                                                
______________________________________                                    
Logistic Regression for Percent                                           
Successful Erectile Function                                              
EFFECT            DF       X.sup.2                                        
                                  P-value                                 
______________________________________                                    
Treatment         2        15.36  0.0005                                  
Stimulus          1        5.14   0.0233                                  
Treatment by Stimulus                                                     
                  2        0.00   1.0000                                  
Contrasts                                                                 
Erotic: Placebo vs. Treatment                                             
                  1        9.60   0.0019                                  
Erotic: 3 mg vs. 4 mg                                                     
                  1        0.00   1.0000                                  
Neutral: Placebo vs. Treatment                                            
                  1        9.60   0.0019                                  
Neutral: 3 mg vs. 4 mg                                                    
                  1        0.00   1.0000                                  
______________________________________                                    
 Note: Analysis performed using SAS PROC CATMOD.                          

              TABLE IX                                                    
______________________________________                                    
Visual Analogue Scale (VAS)                                               
(to be completed by the patient)                                          
Please mark each line clearly at the point which indicates how you are    
feeling right now. Each line represents the full range of each feeling.   
(There are no right or wrong answers)                                     
                        Score (mm)                                        
______________________________________                                    
1.    Alert        -      Drowsy                                          
2.    Calm         -      Excited                                         
3.    Yawning      -      Not Yawning                                     
4.    Fuzzy        -      Clear Headed                                    
5.    Well Coordinated                                                    
                   -      Clumsy                                          
6.    Tired        -      Energetic                                       
7.    Contented    -      Disconnected                                    
8.    Troubled     -      Tranquil                                        
9.    Mentally slow                                                       
                   -      Quick Witted                                    
10.   Tense        -      Relaxed                                         
11.   Attentive    -      Dreamy                                          
12.   Stomach Upset                                                       
                   -      Feeling Well                                    
13.   Anxious      -      Carefree                                        
                (measure from left to right)                              
______________________________________
Dose Evaluation Study
Clinical response to sublingual administration of apomorphine was evaluated utilizing a group of 60 non-vasculogenic impotent patients. Each patient had a history of erectile dysfunction for at least 3 months, normal biothesiometry response, and normal cavernosometry results.
The patients were divided into seven groups. Each group received a predetermined dosage of apomorphine for 20 days in the form of apomorphine hydrochloride tablets 20 minutes prior to intercourse. Seven different dosages were evaluated--3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg and 10 mg The tablet constituents were those shown in Table I, above. Assessment of response was made on the basis of the patient's report of his experience. A response was deemed positive when the patient experienced an erection sufficiently rigid to effect penetration. Side effects such as nausea and/or vomiting, if present, were noted as well.
The results of this study are compiled in Table X, below.
              TABLE X                                                     
______________________________________                                    
Results of Dose Evaluation Study                                          
                Positive                                                  
No. of Dosage,  Responses  Nausea   Vomiting                              
Patients                                                                  
       mg       No.     %    No.   %    No.   %                           
______________________________________                                    
 5     3        0        0   0      0   0      0                          
 5     4        2       40   1     20   1     20                          
10     5        5       50   2     20   1     10                          
10     6        7       70   2     20   2     20                          
10     7        7       70   2     20   2     20                          
10     8        7       70   3     30   3     30                          
10     10       8       80   4     40   4     40                          
______________________________________
From the foregoing Table it can be seen that at a 4-mg dosage 40 percent of patients had a positive response, at a 5-mg dosage 50 percent of patients had a positive response, at 6-mg, 7-mg, and 8-mg dosages 70 percent of patients had a positive response and at a 10-mg dosage 80 percent of patients had a positive response. However, the incidence of side effects increased as well as the dosage was increased.
The aforesaid apomorphine dosage forms are also well suited for diagnosing male human patients suffering from male erectile dysfunction. For diagnostic purposes, at least about 3 milligrams of apomorphine are administered sublingually to the patient and the patient is exposed to a visual erotic stimulus, e.g., an erotic videotape, while the patient's response thereto is monitored. If deemed desirable for diagnostic purposes, up to about 10 milligrams of apomorphine can be administered to the patient.
In particular, the patient's maximum increase in penile circumference (preferably tip as well as basal) is determined and the patient's maximum penile rigidity (preferably tip as well as basal) is determined. The determined circumferential increase and rigidity values are then compared against a predetermined base value. Equivalent methods of determining tumescence and rigidity can also be utilized.
Pilot Study #5
A clinical study, "Absorption and pharmacokinetic evaluation of apomorphine after sublingual and intravenous routes of administration" compared the absorption and pharmacokinetic profile of apomorphine administered intravenously and slowly at a 1 mg dose with apomorphine sublingual tablets at doses of 4 mg (Table I) and 8 mg administered on 3 occasions, 4 days apart, over a 12 day period in a cross-over study design. The tolerance for apomorphine for each route and each dose administered was determined.
The study was conducted as an open-label, single center, 3-way crossover design. The study population was seven healthy, Caucasian male volunteers between 18 and 35 years of age. A 15-day pre-study evaluation period was followed by a 12-day active treatment phase. Three doses (one intravenous; 2 sublingual) were administered to each subject in random order 4 days apart. A total of 36 serum samples were obtained from each subject at the following time periods: 0, 2, 3, 5, 10, 20, 30 and 45 minutes; and 1, 2, 3, 4 and 6 hours post dose administration.
Safety was assessed within 15 days prior to study start and within one week after the last dose was administered. General physical examination was performed. Change from baseline in vital signs, height/weight measurements, ECG, orthostatic arterial pressures, heart rate, serum chemistry profile, hematology profile and urinalysis were recorded. Adverse experiences were recorded at each visit and tabulated.
Data Analysis
1. Pharmacokinetic Analysis
Pharmacokinetic analysis was performed by compartmental and noncompartmental methods described below. Nonlinear, iterative, least-squares regression analysis was performed with the computer program, PPHARM (Simed Co., Philadelphia, Pa.).
A. Compartmental Analysis
The apomorphine plasma concentration data for each subject following intravenous administration was fitted to two-compartment open model with a first order input function as described by the following equations.
Plasma apomorphine concentration was described for intravenous administration data by equation (1):
C.sub.t =Ae.sup.-αt +Be.sup.-βt                 (1)
Plasma apomorphine concentration was described for sublingual tablet administration by equations (2) and (3): ##EQU1##
In the above equations, Ct is the apomorphine plasma concentration at time t; F is the relative bioavailability, which is assumed to be one for intravenous administration; Ka is the first order rate constant for sublingual absorption; Ke is the first order rate constant for elimination; Vd is the volume of distribution; D is the apomorphine dose; t is time; tlag is the lag time before onset of sublingual absorption; A, B, C are the intercepts of the distribution, elimination, and absorption phases, respectively; α is the distribution rate constant; β is the elimination rate constant; and Ka is the absorption rate constant.
Initial estimates of the intravenous and sublingual pharmacokinetic parameters were obtained with the computer program PPHARM (Simed Co., Philadelphia, Pa.). These initial estimates were used to fit the data to equations (1), (2) and (3) by nonlinear iterative least squares regression analysis. The results are shown graphically in FIG. 4. The estimate of F (relative bioavailability) for sublingual administration was obtained from the noncompartmental analysis outlined below.
Visual inspection of the fitted curves, analysis of the residual plots, the Akaike information criterion, and correlation coefficients between observed and calculated values were used to select the appropriate pharmacokinetic model for each set of plasma concentration versus time data. A weighting factor was used to fit the data.
The regression analysis provided the final estimates of the pharmacokinetic parameters: Vd, Ke, Ka, and tlag from equation (2), and A, B, C, α, β, ka, and tlag from equation (3). The maximum plasma concentration (Cmax) , time to maximum plasma concentration (Tmax) , and Vd (volume of distribution) were calculated using standard compartmental pharmacokinetic equations (Gibaldi, M. & Perrier, D. Pharmacokinetics, 2d edition, Marcel Dekker, Inc. New York, 1982).
The values for Cmax and Tmax obtained by visual inspection of the plasma concentration versus time curve were reported for comparative purposes. Model dependent and independent pharmacokinetic parameters (presented in Tables XI-XIV) were calculated for each patient using the best fit of Equation (3) to the data.
B. Noncompartmental Analysis:
The area under the curve, AUCo-inf, was determined by adding the AUCo-last to the AUCt-last, where AUCt-last =Ct/Re, Ct is the plasma concentration at time t, and Re is Ke, the first order rate constant for elimination.
If the plasma concentration versus time data for a subject could not be adequately fit to equation (1), (2) or (3), the Ke was determined by linear regression analysis of the log plasma concentration versus time during the post-absorption phase. Estimates of noncompartmental parameters Cmax and Tmax were obtained from visual inspection of the plasma concentration time curves.
The relative bioavailability (F) for a sublingual dose was calculated by the following equation: ##EQU2## 2. Statistical Analysis:
An analysis of variance (ANOVA) for a three-way crossover study design was utilized to compare the pharmacokinetic parameters (AUC, Cmax, and tlag) determined as described above for the intravenous administration at 1 mg dose and those determined for the sublingual administration of apomorphine at the 4 mg and the 8 mg doses. The ANOVA was tested for the presence of any period or residual carryover effects in the data. Statistical significance was set at an alpha level equal to 0.05. The ability of the ANOVA to detect both a 20% difference and the observed difference between the sublingual and intravenous pharmacokinetic parameters was determined. In addition to the ANOVA, the 95% confidence interval of the percent difference between the sublingual and SC parameters was calculated from the error variance and degrees of freedom of the ANOVA model.
The data were summarized as the mean ± standard deviation in Tables XI-XIV below.
                                  TABLE XI                                
__________________________________________________________________________
NONCOMPARTMENTAL PHARMACOLOGIC PARAMETERS                                 
(MEAN ± SD) AND RANGE                                                  
       IV Administration  4 mg Dose        8 mg Dose                      
Parameter                                                                 
       Mean ±SD                                                        
                Low  High Mean                                            
                              ±SD                                      
                                  Low High Mean ±SD                    
                                                     Low  High            
__________________________________________________________________________
Ke (min.sup.-1)                                                           
       0.0237                                                             
            0.0140                                                        
                0.0091                                                    
                     0.0432                                               
                          0.0156                                          
                              0.0138                                      
                                  0.0038                                  
                                      0.0336                              
                                           0.0056                         
                                                0.0036                    
                                                     0.0222               
                                                          0.0102          
T.sub.1/2 (min)                                                           
       39.44                                                              
            0.219                                                         
                16.04                                                     
                     76.49                                                
                          89.18                                           
                              75.43                                       
                                  20.62                                   
                                      183.60                              
                                           176.30                         
                                                112.30                    
                                                     68.09                
                                                          314.6           
Tmax (min)                                                                
       2.286                                                              
            1.254                                                         
                1.000                                                     
                     5.000                                                
                          17.50                                           
                              18.48                                       
                                  5.000                                   
                                      45.00                               
                                           52.50                          
                                                85.10                     
                                                     5.000                
                                                          15.00           
Cmax (min)                                                                
       8.364                                                              
            3.886                                                         
                3.400                                                     
                     12.90                                                
                          0.8375                                          
                              0.6848                                      
                                  0.3000                                  
                                      0.8500                              
                                           2.069                          
                                                2.366                     
                                                     0.5750               
                                                          1.150           
AUC (0-inf)                                                               
       206.9                                                              
            45.47                                                         
                140.8                                                     
                     260.1                                                
                          31.64                                           
                              18.62                                       
                                  10.13                                   
                                      55.55                               
                                           339.9                          
                                                459.2                     
                                                     15.00                
                                                          316.6           
(min*ng/ml)                                                               
Cl (ml/min)                                                               
       0.0051                                                             
            0.0012                                                        
                0.0038                                                    
                     0.0071                                               
                          0.0456                                          
                              0.0361                                      
                                  0.0180                                  
                                      0.0988                              
                                           0.2056                         
                                                0.2460                    
                                                     0.0253               
                                                          0.5333          
Vd (beta) (ml)                                                            
       0.2344                                                             
            0.1532                                                        
                0.0056                                                    
                     0.4982                                               
                          4.076                                           
                              2.053                                       
                                  1.017                                   
                                      5.277                               
                                           69.09                          
                                                115.80                    
                                                     7.932                
                                                          64.27           
Vd (SS) (ml)                                                              
       0.1942                                                             
            0.0817                                                        
                0.1357                                                    
                     0.3401                                               
                          1.836                                           
                              0.7112                                      
                                  0.999                                   
                                      2.475                               
                                           46.30                          
                                                74.46                     
                                                     6.523                
                                                          12.42           
MRT (min)                                                                 
       40.29                                                              
            18.90                                                         
                20.14                                                     
                     75.32                                                
                          64.25                                           
                              55.14                                       
                                  15.12                                   
                                      137.5                               
                                           143.7                          
                                                148.0                     
                                                     23.29                
                                                          329.3           
F* (% Relative                                                            
            --  --        0.04                                            
                              (4.0%)       0.21 (21%)                     
Bioavailability)                                                          
__________________________________________________________________________
 F* = (AUC.sub.SL *DOSE.sub.IV)/(AUC.sub.IV *DOSE.sub.SL)                 
 Cl = clearance                                                           
 Vd = volume of distribution @ β stage.                              
 Vd (SS) = volume of distribution steady state                            
 MRT = means residual time                                                

                                  TABLE XII                               
__________________________________________________________________________
Noncompartmental Pharmacokinetic Parameters (Mean ± SD) for IV         
Administration (1 mg)                                                     
n = 7                                                                     
        Subject             Subject        Range                          
        #1   #2   #3   #4   #5   #6   #7   Mean ±SD                    
                                                     Low  High            
__________________________________________________________________________
Ke (/min)                                                                 
        0.0432                                                            
             0.0129                                                       
                  0.0091                                                  
                       0.0419                                             
                            0.0168                                        
                                 0.0150                                   
                                      0.0268                              
                                           0.0237                         
                                                0.0140                    
                                                     0.0091               
                                                          0.0432          
T.sub.1/2 (min)                                                           
        16.04                                                             
             53.79                                                        
                  76.49                                                   
                       16.56                                              
                            41.22                                         
                                 46.18                                    
                                      25.84                               
                                           39.44                          
                                                21.92                     
                                                     16.04                
                                                          76.49           
Tmax (min)                                                                
        2.000                                                             
             2.000                                                        
                  2.000                                                   
                       2.000                                              
                            2.000                                         
                                 5.000                                    
                                      1.000                               
                                           2.286                          
                                                1.254                     
                                                     1.000                
                                                          5.000           
Cmax (ng/ml)                                                              
        8.400                                                             
             11.200                                                       
                  4.150                                                   
                       12.250                                             
                            12.900                                        
                                 3.400                                    
                                      6.250                               
                                           8.364                          
                                                3.886                     
                                                     3.400                
                                                          12.900          
AUC (0-inf)                                                               
        140.8                                                             
             255.4                                                        
                  221.5                                                   
                       177.1                                              
                            224.6                                         
                                 169.0                                    
                                      260.1                               
                                           206.9                          
                                                45.47                     
                                                     140.8                
                                                          260.1           
(min*ng/ml)                                                               
Cl (ml/min)                                                               
        0.0071                                                            
             0.0039                                                       
                  0.0045                                                  
                       0.0056                                             
                            0.0045                                        
                                 0.0059                                   
                                      0.0038                              
                                           0.0051                         
                                                0.0012                    
                                                     0.0038               
                                                          0.0071          
Vd (beta) (ml)                                                            
        0.1643                                                            
             0.3039                                                       
                  0.4982                                                  
                       0.0056                                             
                            0.2648                                        
                                 0.2574                                   
                                      0.1466                              
                                           0.2344                         
                                                0.1532                    
                                                     0.0056               
                                                          0.4982          
Vd (SS) (ml)                                                              
        0.1430                                                            
             0.1512                                                       
                  0.3401                                                  
                       0.1147                                             
                            0.2174                                        
                                 0.2574                                   
                                      0.1357                              
                                           0.1942                         
                                                0.0817                    
                                                     0.1357               
                                                          0.3401          
MRT (min)                                                                 
        20.14                                                             
             38.62                                                        
                  75.32                                                   
                       20.32                                              
                            48.42                                         
                                 43.50                                    
                                      35.31                               
                                           40.29                          
                                                18.90                     
                                                     20.14                
                                                          75.32           
__________________________________________________________________________

                                  TABLE XIII                              
__________________________________________________________________________
Noncompartmental Pharmacokinetic Parameters (Mean ± SD) for Sublingual 
Administration                                                            
(4 mg Dose)                                                               
n = 4                                                                     
       Subjects          Range                                            
       #1  #3  #6   #7   Mean                                             
                             ±SD                                       
                                 Low High                                 
__________________________________________________________________________
Ke (/min)                                                                 
       0.0188                                                             
           0.0336                                                         
               0.0060                                                     
                    0.0038                                                
                         0.0156                                           
                             0.0138                                       
                                 0.0038                                   
                                     0.0336                               
T.sub.1/2 (min)                                                           
       36.78                                                              
           20.62                                                          
               115.7                                                      
                    183.6                                                 
                         89.18                                            
                             75.43                                        
                                 20.62                                    
                                     183.6                                
Tmax (min)                                                                
       10.00                                                              
           10.00                                                          
               5.000                                                      
                    45.00                                                 
                         17.50                                            
                             18.48                                        
                                 5.000                                    
                                     45.00                                
Cmax (ng/ml)                                                              
       0.8500                                                             
           1.8000                                                         
               0.3000                                                     
                    0.4000                                                
                         0.8375                                           
                             0.6848                                       
                                 0.3000                                   
                                     0.8500                               
AUC (0-inf)                                                               
       10.13                                                              
           29.25                                                          
               31.64                                                      
                    55.55                                                 
                         31.64                                            
                             18.62                                        
                                 10.13                                    
                                     55.55                                
(min*ng/ml)                                                               
Cl (ml/min)                                                               
       0.0988                                                             
           0.0342                                                         
               0.0316                                                     
                    0.0180                                                
                         0.0456                                           
                             0.0361                                       
                                 0.0180                                   
                                     0.0988                               
Vd (beta) (ml)                                                            
       5.241                                                              
           1.017                                                          
               5.277                                                      
                    4.769                                                 
                         4.076                                            
                             2.053                                        
                                 1.017                                    
                                     5.277                                
Vd (SS) (ml)                                                              
       1.494                                                              
           0.999                                                          
               2.377                                                      
                    2.475                                                 
                         1.836                                            
                             0.7112                                       
                                 0.999                                    
                                     2.475                                
MRT (min)                                                                 
       15.12                                                              
           29.23                                                          
               75.19                                                      
                    137.47                                                
                         64.25                                            
                             55.14                                        
                                 15.12                                    
                                     137.47                               
__________________________________________________________________________

                                  TABLE XIV                               
__________________________________________________________________________
Noncompartmental Pharmacokinetic Parameters (Mean ± SD) for Sublingual 
Administration (8 mg Dose)                                                
n = 4                                                                     
       Subjects           Range                                           
       #2   #3   #4  #6   Mean ±SD                                     
                                    Low High                              
__________________________________________________________________________
Ke (/min)                                                                 
       0.0067                                                             
            0.0032                                                        
                 0.0120                                                   
                     0.0022                                               
                          0.0056                                          
                               0.0036                                     
                                    0.0022                                
                                        0.0102                            
T.sub.1/2 (min)                                                           
       104.0                                                              
            218.4                                                         
                 68.09                                                    
                     314.6                                                
                          176.3                                           
                               112.3                                      
                                    68.09                                 
                                        314.6                             
Tmax (min)                                                                
       180.0                                                              
            10.00                                                         
                 15.00                                                    
                     5.000                                                
                          52.50                                           
                               85.10                                      
                                    5.000                                 
                                        180.0                             
Cmax (ng/ml)                                                              
       5.600                                                              
            1.150                                                         
                 0.9500                                                   
                     0.5750                                               
                          2.069                                           
                               2.366                                      
                                    0.5750                                
                                        5.600                             
AUC (0-inf)                                                               
       996.6                                                              
            316.6                                                         
                 31.25                                                    
                     15.00                                                
                          339.9                                           
                               459.2                                      
                                    15.00                                 
                                        996.6                             
(min*ng/ml)                                                               
Cl (ml/min)                                                               
       0.008                                                              
            0.0253                                                        
                 0.2560                                                   
                     0.5333                                               
                          0.2056                                          
                               0.2460                                     
                                    0.008                                 
                                        0.5333                            
Vd (beta) (ml)                                                            
       1.204                                                              
            7.932                                                         
                 25.15                                                    
                     242.1                                                
                          69.09                                           
                               115.8                                      
                                    1.204                                 
                                        242.1                             
Vd (SS) (ml)                                                              
       157.9                                                              
            8.320                                                         
                 6.523                                                    
                     12.42                                                
                          46.30                                           
                               74.46                                      
                                    6.523                                 
                                        157.9                             
MRT (min)                                                                 
       196.7                                                              
            329.3                                                         
                 25.48                                                    
                     23.29                                                
                          143.7                                           
                               148.0                                      
                                    23.29                                 
                                        329.3                             
__________________________________________________________________________

                                  TABLE XV                                
__________________________________________________________________________
Summary of Pharmacokinetic Parameters for Apomorphine HCl in Humans       
                  PUBLISHED DATA                                          
                  Durif, F. et al.,                                       
                  Neuropharm.                                             
                  Clin.  Gancher, S. T., et al.                           
                                   Montastruc, J. L., et al.              
                  16:157-166                                              
                         Movement Disorders                               
                                   Clin. Neuropharmacol.                  
         THIS STUDY                                                       
                  (1993) 6:212-216 (1991).                                
                                   14:432-437 (1991).                     
ROUTE    i.v.                                                             
            s.l.                                                          
               s.l.                                                       
                  s.l.                                                    
                     s.l.                                                 
                         s.l.                                             
                            s.c.                                          
                               i.v.                                       
                                   s.l.  s.c.                             
__________________________________________________________________________
# Subjects                                                                
         7  7  7  7  7   5  5  5   9     9                                
# Tablets ×                                                         
         n/d                                                              
            1 × 4                                                   
               1 × 8                                                
                  7 × 3                                             
                     14 × 3                                         
                         3 × 6                                      
                            n/a                                           
                               n/a 10 × 3                           
                                         n/a                              
Strength (mg)                                                             
Dose (mg/kg)                                                              
         0.01                                                             
            0.00                                                          
               0.114                                                      
                  0.3                                                     
                     0.6 0.25                                             
                            0.02                                          
                               0.038                                      
                                   0.42  0 04                             
Cmax (ng/ml)                                                              
         8.3                                                              
            0.83                                                          
               2.07                                                       
                  7.5                                                     
                     22.7                                                 
                         14.3                                             
                            19.36                                         
                               31.2                                       
                                   28    26                               
T.sub.max (min)                                                           
         2.2                                                              
            17.5                                                          
               52.5                                                       
                  31.5                                                    
                     38.3                                                 
                         45 6.5                                           
                               6.7 41    18                               
AUC (min*ng/ml)                                                           
         207                                                              
            31.6                                                          
               340                                                        
                  929                                                     
                     2,277                                                
                         1,057                                            
                            592.7                                         
                               881.1                                      
                                   1,882 837                              
Cl (l/hr/kg)                                                              
         4.37                                                             
            n/d                                                           
               n/d                                                        
                  2.1                                                     
                     1.8 n/d                                              
                            n/d                                           
                               n/d n/d   n/d                              
Vd (l/kg)                                                                 
         3.35                                                             
            2.33                                                          
               2.07                                                       
                  3.4                                                     
                     2.8 n/d                                              
                            n/d                                           
                               0.043*                                     
                                   n/d   n/d                              
MRT (min)                                                                 
         40.3                                                             
            64.2                                                          
               143.7                                                      
                  128                                                     
                     125 n/d                                              
                            n/d                                           
                               n/d n/d   n/d                              
T.sub.1/2 (min)                                                           
         39.4                                                             
            89.2                                                          
               176.3                                                      
                  72 70  n/d                                              
                            n/d                                           
                               n/d n/d   n/d                              
Bioavailability (F)                                                       
         n/a                                                              
            4% 21%                                                        
                  10%                                                     
                     10% 17%                                              
                            n/a                                           
                               n/a n/d   n/a                              
__________________________________________________________________________
 n/d = not done                                                           
 n/a = not applicable                                                     
 *Calculated Clin. Neuropharm. 16:157-166 (1993)
The results, summarized in Tables XI-XIV above and shown graphically in FIG. 4, show that the plasma concentration of apomorphine drops quickly when the drug is administered intravenously. In contrast, the plasma concentration of apomorphine rises slowly to a lower level when administered sublingually.
The importance of these findings is put into perspective when compared to information on the administration of apomorphine that is available in the literature (Table XV). The sublingual administration of apomorphine by the present invention produced a lower plasma concentration than the administration and dosage regimes listed for previous reports.
Pilot Study #6
A clinical study of patient tolerance of escalating doses in sublingual tablet administration of APO for the treatment of psychogenic male erectile dysfunction was performed. The pilot study compared the effects of sublingual tablet administration of placebo, and 4, 6 and 8 mg apomorphine hydrochloride (APO) on male erectile dysfunction as measured by Rigiscan™ monitoring and self-reported satisfaction with the treatment results.
The study included 50 men with psychogenic male erectile dysfunction (MED). The study was conducted in three phases. In the first phase, the subject's penile erectile response (measured with the Rigiscan™ ambulatory tumescence monitor) was evaluated. The subject received a placebo tablet for sublingual administration and then viewed a 30-minute video consisting of two 10-minute erotic sequences separated by a 10-minute neutral sequence. Subjects completed a visual analogue scale questionnaire (VAS, Table VI) about their feelings and well-being.
In the second phase, subjects returned to the clinic for four visits, each visit one week apart. Subjects received one sublingual administration of either placebo, or 4, 6 and 8 mg APO at each visit. Doses of APO were administered in ascending order with the placebo being randomly assigned for use at one of the four visits. The procedures performed before and after drug administration were the same as those in the first phase. After completion of the fourth visit, the investigator determined for each subject the most effective and well-tolerated APO dose for home use in the third phase of the study.
The third phase, a home-use phase, lasted 5 weeks. During this phase, subjects attempted coitus at least once each week after taking a single APO tablet. After each attempt the subject and his partner completed a Sexual Function questionnaire (Table XVI). Subjects had a final evaluation at the end of the 5-week, home-use phase.
Fifty males with psychogenic MED were enrolled in this three phase trial. The first aim of this study was to determine the safety and tolerance of APO in the treatment of MED. Several adverse events directly linked with administration of APO in humans were expected: yawning, nausea, vomiting, and cardiovascular effects. Indeed, nausea was the primary adverse event reported in this trial with an overall incidence of less than 13% of the subjects for all administered doses and only two cases were considered severe. The incidence of vomiting was less than 3% for all administered doses.
Hypotension was reported as an adverse event in some subjects in this study, along with bradycardia, dizziness, syncope, and pallor. Only single cases of hypotension and pallor were judged severe in this study. Increased sweating and fatigue were also reported. One of the cases of increased sweating was considered severe. The other severe adverse events (mouth edema, dysphagia, upper respiratory tract infection) were judged unrelated to treatment.
Changes in the serum chemistry values and vital signs paralleled the adverse event reports. There were no clinically significant changes except for one subject judged to have abnormal liver function of unknown origin. There were no clinically significant changes in the blood or urinalysis values due to drug.
The efficacy of APO was evaluated during the first two phases of the study in which subjects were attached to the Rigiscan™ monitor. Subjects were initially treated with placebo in the first phase. In the second phase, patients received 4, 6 and 8 mg APO tablets with a placebo tablet randomly interspersed in the treatment.
There were highly significant effects of APO treatment compared to placebo. These observations indicate that APO has effects on penile function in both erotic and neutral environments (Tables XVII-XIX) . All summed scores showed significant treatment effects at one or more of the three doses of APO. The overall Rigiscan™ score results were significant to highly significant for a treatment effect of 4, 6 and 8 mg compared to the initial placebo. In addition, most of the treatment effects were significant to highly significant compared to the second placebo.
The effects in the erotic video sequences were larger than the effects in the neutral video sequence (TABLES XVII-XIX). Effects in erotic video sequence one were larger than the effects in erotic video sequence two (TABLE XVII). More significant treatment effects were seen in response to the neutral video sequence, but this reflects the larger number of subjects in this data subset, as one center did not show the erotic video sequences. All doses of APO were effective in causing erections (Rigiscan™ reading ≧15 in the presence of erotic stimulation; TABLE XVII).
During the third phase, subjects had recorded at baseline, their satisfaction, erection, number of attempts, and successful intercourse on a VAS scale. Evaluable subjects first recorded a success rate, then completed VAS for erection results and satisfaction with intercourse following take-home treatment. Success rate was calculated for mg as well as μg/kg body weight doses (males). Several evaluations of the data were made including the male and female responses to treatments. The overall average success rate is 69% with APO treatment which is much higher than the average baseline rate 28% (Tables XX, XX1).
The success rate showed numerical increase at tablet strength from 4 mg to 6 mg, but a decrease at 8 mg (TABLE XX). The highest success rate was 73% in both males and females at a tablet strength of 6 mg (TABLE XX). When the dosage is examined as a function of body weight, a dosage range of 50-74 μg/kg gave the highest success rate(: 82%) in females and (80%) in males (Table XXI). The dosage range of 35-50 μg/kg gave the highest success rate.
The optimal response was observed with 4 or 6 mg APO sublingual tablets which caused erections in the majority (72%) of men with male erectile dysfunction (MED) with few severe adverse effects.
                                  TABLE XVI                               
__________________________________________________________________________
SEXUAL FUNCTION STUDY HOME QUESTIONNAIRE - Male                           
Please answer questions within 12-24 hours of taking sublingual           
__________________________________________________________________________
tablet.                                                                   
  Initials:    Subject #:                                                 
                       Today's Date:      Time:                           
                       Date Tablet Taken:   Time:                         
The lines below represent the full range of feeling or response. Please   
mark each line clearly with a vertical                                    
(straight up and down) stroke at the point which represents your          
response. (There are no right or wrong answers.                           
Do not write in boxes on right.)                                          
  What was your erection result after taking the sublingual tablet?       
                       Rigid Erection                                     
  No                   Suitable for                                       
  Erection             Penetration   !                                    
  Did you have intercourse with     !Yes   !No                            
  wife/partner after taking tablet?                                       
  IF NO. please circle 0 - No erection.                                   
  all reasons that apply:                                                 
                       1 - Erection not sufficient for penetration.       
                       2 - Felt sick after taking tablet. (Describe below 
                       in #4.)                                            
                       3 - I decided not to participate in intercourse.   
                       4 - Wife/partner decided not to participate.       
                       5 - Unrelated interruption (example, telephone     
                       call).                                             
                       6 - Wife/partner menstruating.                     
                       7 - Other, explain:                                
  What was your level of satisfaction with this attempt at sexual         
  intercourse?                                                            
  Extremely            Extremely                                          
  Unsatisfied          Satisfied   !                                      
  Please describe any adverse reactions you experienced after taking the  
  sublingual tablet. (Indicate when the                                   
  reaction started and stopped, and any intervention taken i.e.           
  "nosebleed on 5/1/94, used a cold compress".)                           
  Other comments?                                                         
__________________________________________________________________________

                                  TABLE XVII                              
__________________________________________________________________________
Total Rigiscan Scores by Phase                                            
Mean ± SEM                                                             
Phase II                                                                  
     Phase I                                                              
           Phase II                                                       
Video                                                                     
     Placebo 1                                                            
           Placebo 2                                                      
                 4 mg    6 mg   8 mg                                      
__________________________________________________________________________
Erotic 1                                                                  
     11.44 ± 1.77                                                      
           13.38 ± 2.05                                                
                 15.31 ± 1.76*                                         
                         17.09 ± 1.64**                                
                                19.84 ± 1.61**                         
N = 31-36                                                                 
Erotic 2                                                                  
     11.39 ± 1.70                                                      
           13.31 ± 1.88                                                
                 15.26 ± 1.72*                                         
                         16.44 ± 1.98*                                 
                                17.79 ± 1.96**                         
N = 29-36                                                                 
Neutral                                                                   
      7.98 ± 1.24                                                      
            7.49 ± 1.26                                                
                  11.11 ± 1.30**                                       
                         12.76 ± 1.12**                                
                                11.98 ± 1.37**                         
N = 41-48                                                                 
Corresponding p-values (placebl 1/placebo 2)                              
Erotic 1                                                                  
     --    0.3274                                                         
                 0.0120  0.0007 0.0001                                    
     --    --    0.1405  0.0166 0.0005                                    
Erotic 2                                                                  
     --    0.4013                                                         
                 0.0276  0.0196 0.0007                                    
     --    --    0.1907  0.1365 0.0091                                    
Neutral                                                                   
     --    0.6243                                                         
                 0.0230  0.0009 0.0060                                    
     --    --    0.0074  0.0002 0.0017                                    
__________________________________________________________________________
 *Significantly higher than placebo 1                                     
 **Significantly higher than placebo 1 and placebo 2                      

                                  TABLE XVIII                             
__________________________________________________________________________
Penile Measurements (Maximum Increases Measured by Rigiscan ™). Erotic 
Video Sequence #1                                                         
Repeated Measures Analysis of Variance                                    
                DESCRIPTIVE                                               
                         ADJUSTED                                         
                STATISTICS                                                
                         (LS) MEAN                                        
ANALYSIS OF VARIANCE----                                                  
Site  Treatment N MEAN                                                    
                      SEM                                                 
                         LSMEAN                                           
                              SEM                                         
                                 Source    p-value                        
__________________________________________________________________________
ALL SITES                                                                 
      Placebo #1                                                          
                36                                                        
                  11.44                                                   
                      1.770                                               
                         12.22                                            
                              1.666                                       
                                 Treatment 0.0001 *                       
      Placebo #2                                                          
                32                                                        
                  13.38                                                   
                      2.051                                               
                         13.65                                            
                              1.714                                       
                                 Site      0.0264 *                       
      4 mg      35                                                        
                  15.31                                                   
                      1.761                                               
                         15.80                                            
                              1.674                                       
                                 Treatment by Site                        
                                           0.0595                         
      6 mg      34                                                        
                  17.09                                                   
                      1.841                                               
                         17.20                                            
                              1.695                                       
                                 4 mg vs Placebo #1                       
                                           0.0120 *                       
      8 mg      31                                                        
                  19.84                                                   
                      1.610                                               
                         19.11                                            
                              1.745                                       
                                 6 mg vs Placebo #1                       
                                           0.0007 *                       
SITE #1                                                                   
      ALL TREATMENTS                                                      
                11                                                        
                  10.76                                                   
                      2.372                                               
                         11.04                                            
                              2.498                                       
                                 8 mg vs Placebo #1                       
                                           0.0001 *                       
      Placebo #1                                                          
                11                                                        
                  9.73                                                    
                      2.854                                               
                         9.73 2.931                                       
                                 4 mg vs Placebo #2                       
                                           0.1504                         
      Placebo #2                                                          
                10                                                        
                  9.00                                                    
                      3.300                                               
                         9.21 2.996                                       
                                 6 mg vs Placebo #2                       
                                           0.0166 *                       
      4 mg      11                                                        
                  8.09                                                    
                      2.410                                               
                         8.09 2.931                                       
                                 8 mg vs Placebo #2                       
                                           0.0005 *                       
      6 mg      11                                                        
                  10.82                                                   
                      3.065                                               
                         10.82                                            
                              2.931                                       
                                 Placebo #1 vs. #2                        
                                           0.3274                         
      8 mg      9 17.89                                                   
                      2.988                                               
                         17.36                                            
                              3.070                                       
SITE #2                                                                   
      ALL TREATMENTS                                                      
                16                                                        
                  13.89                                                   
                      1.942                                               
                         14.25                                            
                              2.083                                       
      Placebo #1                                                          
                16                                                        
                  8.94                                                    
                      2.233                                               
                         8.94 2.430                                       
      Placebo #2                                                          
                14                                                        
                  11.71                                                   
                      2.768                                               
                         11.38                                            
                              2.515                                       
      4 mg      15                                                        
                  15.27                                                   
                      2.379                                               
                         15.10                                            
                              2.476                                       
      6 mg      15                                                        
                  17.60                                                   
                      2.267                                               
                         17.43                                            
                              2.476                                       
      8 mg      15                                                        
                  18.60                                                   
                      2.265                                               
                         18.43                                            
                              2.476                                       
SITE #4                                                                   
      ALL TREATMENTS                                                      
                9 21.21                                                   
                      3.437                                               
                         21.49                                            
                              2.776                                       
      Placebo #1                                                          
                9 18.00                                                   
                      4.304                                               
                         18.00                                            
                              3.240                                       
      Placebo #2                                                          
                8 21.75                                                   
                      4.242                                               
                         20.36                                            
                              3.337                                       
      4 mg      9 24.22                                                   
                      2.837                                               
                         24.22                                            
                              3.240                                       
      6 mg      8 24.75                                                   
                      3.740                                               
                         23.36                                            
                              3.337                                       
      8 mg      7 25.00                                                   
                      3.259                                               
                         21.52                                            
                              3.444                                       
__________________________________________________________________________

                                  TABLE XIX                               
__________________________________________________________________________
Penile Measurements (Maximum Increases Measured by Rigiscan ™).        
Neutral Video Sequence                                                    
Repeated Measures Analysis of Variance                                    
                DESCRIPTIVE                                               
                         ADJUSTED                                         
                STATISTICS                                                
                         (LS) MEAN                                        
ANALYSIS OF VARIANCE----                                                  
Site  Treatment N MEAN                                                    
                      SEM                                                 
                         LSMEAN                                           
                              SEM                                         
                                 Source    p-value                        
__________________________________________________________________________
ALL SITES                                                                 
      Placebo #1                                                          
                48                                                        
                  7.98                                                    
                      1.236                                               
                         8.34 1.220                                       
                                 Treatment 0.0002 *                       
      Placebo #2                                                          
                43                                                        
                  7.49                                                    
                      1.257                                               
                         7.65 1.272                                       
                                 Site      0.1092                         
      4 mg      47                                                        
                  11.11                                                   
                      1.295                                               
                         11.47                                            
                              1.226                                       
                                 Treatment by Site                        
                                           0.7176                         
      6 mg      45                                                        
                  12.76                                                   
                      1.116                                               
                         13.10                                            
                              1.268                                       
                                 4 mg vs Placebo #1                       
                                           0.0230 *                       
      8 mg      41                                                        
                  11.98                                                   
                      1.366                                               
                         12.40                                            
                              1.331                                       
                                 6 mg vs Placebo #1                       
                                           0.0009 *                       
SITE #1                                                                   
      ALL TREATMENTS                                                      
                11                                                        
                  10.56                                                   
                      1.987                                               
                         10.70                                            
                              1.789                                       
                                 8 mg vs Placebo #1                       
                                           0.0060 *                       
      Placebo #1                                                          
                11                                                        
                  8.91                                                    
                      2.470                                               
                         8.91 2.494                                       
                                 4 mg vs Placebo #2                       
                                           0.0074 *                       
      Placebo #2                                                          
                10                                                        
                  5.60                                                    
                      2.574                                               
                         5.68 2.587                                       
                                 6 mg vs Placebo #2                       
                                           0.0002 *                       
      4 mg      11                                                        
                  10.45                                                   
                      1.965                                               
                         10.45                                            
                              2.494                                       
                                 8 mg vs Placebo #2                       
                                           0.0017 *                       
      6 mg      11                                                        
                  12.73                                                   
                      2.832                                               
                         12.73                                            
                              2.494                                       
                                 Placebo #1 vs. #2                        
                                           0.6243                         
      8 mg      9 16.22                                                   
                      3.099                                               
                         15.73                                            
                              2.692                                       
SITE #2                                                                   
      ALL TREATMENTS                                                      
                16                                                        
                  7.02                                                    
                      1.192                                               
                         7.22 1.495                                       
      Placebo #1                                                          
                16                                                        
                  4.44                                                    
                      1.554                                               
                         4.44 2.068                                       
      Placebo #2                                                          
                14                                                        
                  5.86                                                    
                      2.099                                               
                         5.71 2.182                                       
      4 mg      15                                                        
                  8.73                                                    
                      2.610                                               
                         8.70 2.126                                       
      6 mg      15                                                        
                  9.60                                                    
                      1.514                                               
                         9.56 2.126                                       
      8 mg      15                                                        
                  7.73                                                    
                      1.694                                               
                         7.70 2.126                                       
SITE #3                                                                   
      ALL TREATMENTS                                                      
                12                                                        
                  12.22                                                   
                      1.476                                               
                         12.09                                            
                              1.706                                       
      Placebo #1                                                          
                12                                                        
                  11.33                                                   
                      2.244                                               
                         11.33                                            
                              2.388                                       
      Placebo #2                                                          
                11                                                        
                  10.00                                                   
                      1.902                                               
                         10.61                                            
                              2.469                                       
      4 mg      12                                                        
                  11.83                                                   
                      2.564                                               
                         11.83                                            
                              2.388                                       
      6 mg      12                                                        
                  13.58                                                   
                      1.794                                               
                         13.58                                            
                              2.388                                       
      8 mg      11                                                        
                  12.45                                                   
                      2.458                                               
                         13.07                                            
                              2.469                                       
SITE #4                                                                   
      ALL TREATMENTS                                                      
                9 11.63                                                   
                      2.864                                               
                         12.35                                            
                              2.023                                       
      Placebo #1                                                          
                9 8.67                                                    
                      4.052                                               
                         8.67 2.758                                       
      Placebo #2                                                          
                8 9.25                                                    
                      3.990                                               
                         8.58 2.891                                       
      4 mg      9 14.89                                                   
                      3.071                                               
                         14.89                                            
                              2.758                                       
      6 mg      7 18.14                                                   
                      2.747                                               
                         16.51                                            
                              3.046                                       
      8 mg      6 15.33                                                   
                      4.462                                               
                         13.11                                            
                              3.236                                       
__________________________________________________________________________

              TABLE XX                                                    
______________________________________                                    
Reported Success by Tablet Strength                                       
Group  4 mg      6 mg       8 mg    Overall                               
______________________________________                                    
Female 5/7 (71.4%)                                                        
                 11/15 (73.3%)                                            
                            4/7 (57.1%)                                   
                                    20/29 (69.0%)                         
Male   5/7 (71.4%)                                                        
                 11/15 (73.3%)                                            
                            4/7 (57.1%)                                   
                                    20/29 (69.0%)                         
______________________________________                                    

              TABLE XXI                                                   
______________________________________                                    
Reported Success by Apomorphine Dosage (μg/kg)                         
Group  35-50 μg/kg                                                     
                 50-74 μg/kg                                           
                           >74 μg/kg                                   
                                   Overall                                
______________________________________                                    
Female 3/5 (60.0%)                                                        
                 9/11 (81.8%)                                             
                           8/13 (61.5%)                                   
                                   20/29 (69.0%)                          
Male   4/5 (80.0%)                                                        
                 8/11 (72.7%)                                             
                           8/13 (61.5%)                                   
                                   20/29 (69.0%)                          
______________________________________                                    
 Subject Evaluability Rules for Takehome Part                             
 1. Subjects who get one out of two successful intercourse is considered a
 success  based on subject's answers to the takehome questionnaires!.     
 2. Subjects who tried the study medication at home, for at least two     
 times.                                                                   
 3. Subjects who attempted to try a lower or higher does if the original  
 takehome does did not produce optimum results in combination with        
 antinausea agents.                                                       
 4. Subjects  and partners! who filled out and returned takehome          
 questionnaires.
The foregoing discussion and the reported studies are intended as illustrative of the present invention and are not to be taken as limiting. Still other variants within the spirit and scope of this invention are possible and will readily present themselves to those skilled in the art.

Claims (21)

We claim:
1. A method of ameliorating erectile dysfunction in a psychogenic male patient which comprises administering to said patient apomorphine or a pharmaceutically acceptable acid addition salt thereof sublingually prior to sexual activity, and in an amount sufficient to induce an erection adequate for vaginal penetration but less than the amount that induces nausea.
2. A method of ameliorating erectile dysfunction in a psychogenic male patient which comprises administering to said patient apomorphine or a pharmaceutically acceptable acid addition salt thereof sublingually prior to sexual activity, and in an amount sufficient to induce an erection adequate for vaginal penetration but less than an amount that induces nausea and to maintain a plasma concentration of apomorphine at a level of no more than about 5.5 ng/ml.
3. The method in accordance with claim 2 wherein the plasma concentration of apomorphine is maintained at a level of about 0.3 to about 4 ng/ml.
4. The method in accordance with claim 2 wherein the plasma concentration of apomorphine is maintained at a level of about 1 to about 2 ng/ml.
5. The method in accordance with claim 1 wherein the amount of apomorphine administered is in the range of about 2.5 milligrams to about 10 milligrams.
6. The method in accordance with claim 1 wherein the amount of apomorphine administered is in the range of about 25 to about 75 micrograms per kilogram of body weight.
7. The method in accordance with claim 1 wherein apomorphine is administered as the hydrochloride salt.
8. The dosage form in accordance with claim 1 additionally containing a β-cyclodextrin.
9. The dosage form in accordance with claim 8 wherein the β-cyclodextrin is hydroxypropyl-β-cyclodextrin.
10. A method for diagnosing a male human patient suffering from erectile dysfunction which method comprises the steps of
administering sublingually to the patient apomorphine in an amount sufficient to induce an erection adequate for vaginal penetration but less than an amount that induces nausea; and thereafter, in response to visual erotic stimulus,
determining the patient's maximum increase in penile circumference;
determining the patient's maximum penile rigidity; and
comparing the determined maximum increase and maximum rigidity values against a predetermined base value for erectile dysfunction.
11. The diagnostic method in accordance with claim 10 wherein said maximum increase in penile circumference is determined by measuring penile tip circumference and penile basal circumference, and wherein said maximum rigidity is determined by measuring penile tip rigidity and penile basal rigidity.
12. A method of inducing an erection in a psychogenic male patient which comprises (1) administering to said patient apomorphine or a pharmaceutically acceptable acid addition salt thereof as a sublingual dosage form and in an amount sufficient to induce an erection capable of vaginal penetration but less than an amount that induces nausea and (2) erotically stimulating said psychogenic male patient.
13. The method in accordance with claim 12 wherein the sublingual dosage form contains about 2.5 milligrams to about 10 milligrams of apomorphine.
14. The method in accordance with claim 12 wherein the apomorphine is administered as the hydrochloride salt.
15. The method in accordance with claim 12 wherein the apomorphine is administered together with a β-cyclodextrin.
16. The method in accordance with claim 15 wherein the β-cyclodextrin is hydroxypropyl-β-cyclodextrin.
17. A method of inducing an erection by stimulating dopamine receptors in the mid-brain region of a patient to cause an erection without inducing nausea which comprises administering to the patient apomorphine in a sublingual dose containing about 25 to about 60 micrograms of apomorphine per kilogram of body weight and at a rate so as to maintain a patient's plasma concentration of apomorphine at a value of no more than about 5.5 nanograms per milliliter during sexual activity.
18. The method in accordance with claim 17 wherein the patient's plasma concentration of apomorphine is maintained in the range of about 0.3 to about 4 nanograms per milliliter during sexual activity.
19. The method in accordance with claim 17 wherein the patient's plasma concentration of apomorphine is maintained in the range of about 1 to about 2 nanograms per milliliter during sexual activity.
20. The diagnostic method in accordance with claim 10 wherein at least about 2.5 milligrams of apomorphine are administered to the patient.
21. The diagnostic method in accordance with claim 20 wherein said maximum increase in penile circumference is determined by measuring penile tip circumference and penile basal circumference, and wherein said maximum rigidity is determined by measuring penile tip rigidity and penile basal rigidity.
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US09/102,235 US5985889A (en) 1994-04-22 1998-06-22 Dosage forms and method for ameliorating male erectile dysfunction
US09/336,088 US6395744B1 (en) 1994-04-22 1999-06-18 Method and compositions for the treatment or amelioration of female sexual dysfunction
US09/440,451 US6200983B1 (en) 1994-04-22 1999-11-15 Dosage forms containing apomorphine for ameliorating male erectile dysfunction
US09/606,919 US6306437B1 (en) 1994-04-22 2000-06-29 Apomorphine-containing dosage forms for ameliorating male erectile dysfunction
US10/044,588 US6566368B2 (en) 1994-04-22 2001-10-23 Apomorphine-containing dosage form for ameliorating male erectile dysfunction
US10/126,933 US6756407B2 (en) 1994-04-22 2002-04-22 Method and compositions for the treatment or amelioration of female sexual dysfunction
US10/136,387 US20020165122A1 (en) 1994-04-22 2002-05-02 Method and compositions for the treatment or amelioration of female sexual dysfunction
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